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From the Neurology Department (Drs. Maselli, Bowe, Aigus, and Richman, and D.Z. Kong), Physical Medicine and Rehabilitation Department (Dr. McDonald), Pathology Department (Dr. Ellis), University of California, Davis; Neurology Department (Dr. Gomez), University of Minnesota, Minneapolis; and Pathology Department (Dr. Wollmann), The University of Chicago, IL.
Address correspondence and reprint requests to Dr. Ricardo A. Maselli, UC Davis, 1515 Newton Ct., Rm. 510, Davis, CA 95616; e-mail: ramaselli{at}ucdavis.edu
OBJECTIVE: To provide clinical, electrophysiologic, and ultrastructural findings in three patients with a presynaptic congenital myasthenic syndrome (CMS).
BACKGROUND: Familial infantile myasthenia and paucity of synaptic vesicles are the only two fully characterized CMS. We are describing here three patients with another form of presynaptic CMS characterized by deficiency of the action potential–dependent release without reduction of the spontaneous release of neurotransmitter from the nerve terminal.
METHODS: The authors performed electromyography and anconeus muscle biopsies that included intracellular recordings and electron microscopy of the neuromuscular junction in three patients with presynaptic CMS. They also sequenced part of the P/Q-calcium 
1-subunit gene (CACNA1A) and the acetylcholine receptor subunit (AChR) genes in these patients.
RESULTS: In these patients there were additional neurologic findings including nystagmus and ataxia. In all three patients the end-plate potential quantal content (m) was markedly reduced but neither the amplitudes nor the frequencies of miniature end-plate potentials were diminished. Ultrastructurally, postsynaptic end-plate folds, nerve terminal size, and synaptic vesicle number were normal but double-membrane-bound sacs containing synaptic vesicles were present in the nerve terminal of all three patients. The screening of reported pathogenic mutations in the CACNA1A and a mutational analysis of AChR subunit genes were negative.
CONCLUSION: This form of CMS appears to result only from a deficiency of the quantal release of neurotransmitter that may be due to an abnormal calcium mechanism or impaired endocytosis and recycling of synaptic vesicles.
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