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Zahn C, Puga C, Malik A, Khanna D. Painful Raynaud's mimics. Best Pract Res Clin Rheumatol 2024:101948. [PMID: 38704280 DOI: 10.1016/j.berh.2024.101948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 04/04/2024] [Indexed: 05/06/2024]
Abstract
Raynaud's syndrome is a common finding in many autoimmune conditions. Accurately diagnosing Raynaud's, and differentiating it from mimicking conditions, is imperative in rheumatologic diseases. Raynaud's syndrome and Raynaud's mimickers, especially painful Raynaud's mimickers, can prove a diagnostic challenge for the practicing rheumatologist. Painful Raynaud's mimickers can lead to increased patient stress and unnecessary medical work up; Healthcare providers need to be aware of Raynaud's mimickers when evaluating patient concerns of skin color changes and pain. The present narrative review aims to highlight Raynaud's syndrome, important painful mimickers that may be seen, diagnosis, and updated management recommendations.
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Affiliation(s)
- Carleigh Zahn
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, 300 North Ingalls Building - Rm 7C27, Ann Arbor, MI, 48109, USA.
| | - Cindy Puga
- Cedars Sinai Internal Medicine Residency, 8700 Beverly Blvd, Becker Bldg. B105 A, Los Angeles, CA, 90048, USA.
| | - Aroosa Malik
- Department of Internal Medicine, Division of Vascular Medicine, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Dinesh Khanna
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, 300 North Ingalls Building - Rm 7C27, Ann Arbor, MI, 48109, USA.
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2
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Caldito EG, Caldito NG, Kaul S, Piette W, Mehta S. Erythromelalgia. Part II: Differential diagnoses and management. J Am Acad Dermatol 2024; 90:465-474. [PMID: 37364616 DOI: 10.1016/j.jaad.2023.02.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 02/13/2023] [Accepted: 02/16/2023] [Indexed: 06/28/2023]
Abstract
The management of erythromelalgia is challenging and requires multidisciplinary effort. Patient education is crucial as unsafe self-administered cooling techniques can lead to significant morbidity, including acral necrosis, infection, and amputation. The goal of management is pain control, reduction of flare frequency, and prevention of complications. This text is focused on the management of erythromelalgia and several other incompletely understood and under-recognized neurovascular disorders such as red scrotum syndrome, red ear syndrome, facial flushing, and complex regional pain syndrome.
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Affiliation(s)
| | | | - Subuhi Kaul
- Division of Dermatology, John H Stroger Hospital of Cook County, Chicago, Illinois
| | - Warren Piette
- Division of Dermatology, John H Stroger Hospital of Cook County, Chicago, Illinois; Department of Dermatology, Rush University Medical Center, Chicago, Illinois
| | - Shilpa Mehta
- Division of Dermatology, John H Stroger Hospital of Cook County, Chicago, Illinois.
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3
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Ma JE, Lee JUJ, Sartori-Valinotti JC, Rooke TW, Sandroni P, Davis MDP. Erythromelalgia: A Review of Medical Management Options and Our Approach to Management. Mayo Clin Proc 2023; 98:136-149. [PMID: 36470753 DOI: 10.1016/j.mayocp.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/21/2022] [Accepted: 08/16/2022] [Indexed: 12/05/2022]
Abstract
Erythromelalgia (EM) is a rare disorder characterized by episodic, burning pain associated with erythema and warmth of the extremities. The feet and hands are most commonly affected. The pain can be so severe that patients may engage in behaviors, sometimes extreme, to cool the affected areas and change their lifestyle to avoid precipitating factors, such as exercise and increased ambient heat. A literature search was performed with PubMed and MEDLINE with the search term erythromelalgia. Inclusion criteria were studies on EM published after 1985 until January 1, 2022, in the English language and studies that provided information on medical treatment of EM. Studies were excluded if they were duplicates or did not include treatment data. No guidelines exist for the treatment of this complex disorder. Lifestyle modifications and pharmacologic treatments (topical and systemic) are discussed in this article, which provides a comprehensive review of published medical management options for erythromelalgia and a proposed approach to management.
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Affiliation(s)
- Janice E Ma
- Division of Dermatology, Harbor-UCLA Medical Center, Torrance, CA
| | - Jinnee U J Lee
- Chicago Medical School, Rosalind Franklin University, North Chicago, IL
| | | | - Thom W Rooke
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Mayo Clinic Gonda Vascular Center, Rochester, MN
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Dusch M, Schmelz M. [Erythromelalgia: skin redness and pain]. Schmerz 2019; 33:475-490. [PMID: 31485751 DOI: 10.1007/s00482-019-00401-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Erythromelalgia is a rare disease that is associated with hemato-oncological diseases or after taking certain drugs and toxins, but it can also occur as an independent clinical picture, for example, due to mutations in the sodium channel NaV1.7. Clinically, there is a characteristic triad of attack-like burning pain and skin redness in the area of the distal extremities, which can be alleviated by excessive cooling. The attacks are triggered by heat, exertion, and stress. The diagnosis is primarily made clinically and can be confirmed by genetic testing if a sodium channel NaV1.7 mutation is present. Important differential diagnoses are complex regional pain syndrome, the non-freezing cold injury, and small fiber neuropathies. Therapy is multidisciplinary and has to be planned individually and include physical therapy and psychotherapy as well as drug therapy as integral components.
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Affiliation(s)
- M Dusch
- Klinik für Anästhesiologie und Intensivmedizin, Fachbereich Schmerzmedizin, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
| | - M Schmelz
- Abteilung Experimentelle Schmerzforschung, CBTM, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
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Lee CE, Paulk K, Garvie K, Grieshaber E, Carter J, Ball B. Pediatric erythromelalgia treated with epidural ropivacaine infusion. JAAD Case Rep 2019; 5:306-308. [PMID: 30976641 PMCID: PMC6441710 DOI: 10.1016/j.jdcr.2019.01.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Caroline E Lee
- Department of Dermatology, Louisiana State University, New Orleans, Louisiana
| | - Kelly Paulk
- Department of Physical and Rehabilitative Medicine, Louisiana State University, New Orleans, Louisiana
| | - Kristen Garvie
- School of Medicine, Louisiana State University, New Orleans, Louisiana
| | | | - Jeffrey Carter
- Department of Surgery, Louisiana State University, New Orleans, Louisiana
| | - Brian Ball
- Ketamine Infusion Center, Covington, Louisiana
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6
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Bortoli EI, Sakata RK. Pain management in children with erythromelalgia: case report. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 29402440 PMCID: PMC9391724 DOI: 10.1016/j.bjane.2017.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Erythromelalgia is a neuropathic pain syndrome due to an autosomal dominant gene, characterized by erythema, increased skin temperature and burning pain in hands and feet, whose treatment is often unsatisfactory. In this paper, we report a case of a 9 years old female patient whose first episode of burning pain, erythema and edema of the hands, without triggering factors, had instant relief after immersion in cold water. She presented with systemic arterial hypertension and had seizures. The patient was treated with gabapentin (150 mg.8 h−1) and amitriptyline (12.5 mg) orally, intravenous lidocaine infusion (120 mg), without relieving pain complaints. Due to the lack of response to the proposed treatment, it was decided to gradually reduce these medications and to introduce carbamazepine (200 mg) orally and, after 4 days of treatment, there was complete relief of the manifestations.
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Affiliation(s)
- Estela Irene Bortoli
- Universidade Federal de São Paulo (UNIFESP), Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil
| | - Rioko Kimiko Sakata
- Universidade Federal de São Paulo (UNIFESP), Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil.
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Bortoli EI, Sakata RK. Tratamento da dor em criança com eritromelalgia: relato de caso. Braz J Anesthesiol 2018; 68:531-534. [DOI: 10.1016/j.bjan.2017.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 10/10/2017] [Accepted: 12/28/2017] [Indexed: 10/18/2022] Open
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Tham SW, Giles M. Current pain management strategies for patients with erythromelalgia: a critical review. J Pain Res 2018; 11:1689-1698. [PMID: 30214279 PMCID: PMC6121769 DOI: 10.2147/jpr.s154462] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Erythromelalgia (EM) is a rare disorder characterized by erythematous, warm, painful extremities, which is often precipitated by cold conditions. The pathophysiology of EM is incompletely understood. Recent investigations have identified sodium channelopathy as a genetic cause for this pain condition, classified as primary inherited EM. Other subtypes are idiopathic EM and secondary EM. The management of pain in EM is challenging as no single therapy has been found to be effective. There is varying response to pharmacotherapy and significant variability within this clinical population, resulting in a stepwise trial and error approach. Consequently, EM is often associated with poorer health-related quality of life with higher morbidity. There is currently no consensus or guidelines on management of pain in EM. This is a review of the literature on management of pain using pharmacologic, procedural intervention and nonpharmacologic treatment in children and adults with EM.
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Affiliation(s)
- See Wan Tham
- Seattle Children's Research Institute, Seattle, WA, USA,
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA,
| | - Marian Giles
- Seattle Children's Research Institute, Seattle, WA, USA,
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA,
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Helås T, Sagafos D, Kleggetveit I, Quiding H, Jönsson B, Segerdahl M, Zhang Z, Salter H, Schmelz M, Jørum E. Pain thresholds,supra-threshold pain and lidocaine sensitivity in patients with erythromelalgia, including the I848Tmutation in NaV1.7. Eur J Pain 2017; 21:1316-1325. [DOI: 10.1002/ejp.1030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2017] [Indexed: 11/09/2022]
Affiliation(s)
- T. Helås
- Section of Clinical Neurophysiology, Department of Neurology; Oslo University Hospital - Rikshospitalet; Norway
| | - D. Sagafos
- Section of Clinical Neurophysiology, Department of Neurology; Oslo University Hospital - Rikshospitalet; Norway
| | - I.P. Kleggetveit
- Section of Clinical Neurophysiology, Department of Neurology; Oslo University Hospital - Rikshospitalet; Norway
| | | | | | | | - Z. Zhang
- Astra-Zeneca R&D; Södertälje Sweden
| | - H. Salter
- Astra-Zeneca R&D; Södertälje Sweden
- Department of Clinical Neuroscience; Karolinska Institutet; Solna Sweden
| | - M. Schmelz
- Department of Anesthesiology Mannheim; Heidelberg University; Germany
| | - E. Jørum
- Section of Clinical Neurophysiology, Department of Neurology; Oslo University Hospital - Rikshospitalet; Norway
- Faculty of Medicine, Institute of Clinical Medicine; University of Oslo; Norway
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Kundu A, Rafiq M, Warren PS, Tobias JD. Erythromelalgia in the pediatric patient: role of computed-tomography-guided lumbar sympathetic blockade. J Pain Res 2016; 9:837-845. [PMID: 27799815 PMCID: PMC5079692 DOI: 10.2147/jpr.s110688] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Erythromelalgia (EM) is an uncommon condition characterized by erythema, increased skin temperature, and burning pain, most frequently occurring in the lower extremities. The pain is generally very severe and treatment can be extremely challenging, especially in the pediatric and adolescent population. We report a series of three cases of primary EM in pediatric patients involving the lower extremities, refractory to medical treatment that responded favorably to computed-tomography-guided lumbar sympathetic blockade. There was a significant improvement in pain scores, quality of life, and overall function as well as decreased analgesic requirements. Lumbar sympathetic blockade should be considered as a therapeutic modality in pediatric and adolescent patients with EM who are refractory to other treatments.
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Affiliation(s)
- Anjana Kundu
- Department of Anesthesiology, Dayton Children's Hospital, Dayton
| | | | | | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine; Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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11
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[Erythromelalgia: Diagnosis and therapeutic approach]. Rev Med Interne 2016; 38:176-180. [PMID: 27639908 DOI: 10.1016/j.revmed.2016.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 08/10/2016] [Indexed: 12/29/2022]
Abstract
Erythromelalgia is a rare intermittent vascular acrosyndrome characterized by the combination of recurrent burning pain, warmth and redness of the extremities. It is considered in its primary form as an autosomal dominant neuropathy related to mutations of SCN9A, the encoding gene of a voltage-gated sodium channel subtype Nav1.7. Secondary erythromelalgia is associated with myeloproliferative disorders, drugs (bromocriptine, calcium channel blockers), or clinical conditions such as rheumatic diseases or viral infection. Primary familial erythromelalgia include genetics and sporadic forms associated with small fibers neuropathy. Aspirin is a useful treatment of erythromelagia associated with myeloproliferative disorders. Treatment of primary erythromelalgia is difficult, individualized, with sodium channel blockers such as lidocaine, carbamazepine and mexiletine.
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Abstract
• Individual variability in pain perception and differences in the efficacy of analgesic drugs are complex phenomena and are partly genetically predetermined. • Analgesics act in various ways on the peripheral and central pain pathways and are regarded as one of the most valuable but equally dangerous groups of medications. • While pharmacokinetic properties of drugs, metabolism in particular, have been scrutinised by genotype–phenotype correlation studies, the clinical significance of inherited variants in genes governing pharmacodynamics of analgesics remains largely unexplored (apart from the µ-opioid receptor). • Lack of replication of the findings from one study to another makes meaningful personalised analgesic regime still a distant future. • This narrative review will focus on findings related to pharmacogenetics of commonly used analgesic medications and highlight authors’ views on future clinical implications of pharmacogenetics in the context of pharmacological treatment of chronic pain.
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Affiliation(s)
- Roman Cregg
- UCL Centre for Anaesthesia, Critical Care & Pain Medicine, London, UK ; Royal Marsden NHS Foundation Trust, London, UK
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Abstract
Voltage-gated sodium channels (NaV) play a crucial role in development and propagation of action potentials in neurons and muscle cells. NaV1.7 channels take a special place in modern science since it is believed that they contribute to nerve hyperexcitability. Mutations of the gene SCN9A, which codes the α subunit of NaV1.7 channels, are associated with pain perception disorders (primary erythermalgia, congenital analgesia, and paroxysmal pain disorder). It is considered that the SCN9A gene mutations may cause variations in sensitivity to pain, from complete insensitivity to extreme sensitivity. Further research of the SCN9A gene polymorphism influence on pain sensitivity is essential for the understanding of the pathophysiology of pain and the development of the appropriate targeted pain treatment.
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Cregg R, Cox JJ, Bennett DLH, Wood JN, Werdehausen R. Mexiletine as a treatment for primary erythromelalgia: normalization of biophysical properties of mutant L858F NaV 1.7 sodium channels. Br J Pharmacol 2014; 171:4455-63. [PMID: 24866741 PMCID: PMC4209151 DOI: 10.1111/bph.12788] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 05/10/2014] [Accepted: 05/17/2014] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND PURPOSE The non-selective sodium channel inhibitor mexiletine has been found to be effective in several animal models of chronic pain and has become popular in the clinical setting as an orally available alternative to lidocaine. It remains unclear why patients with monogenic pain disorders secondary to gain-of-function SCN9a mutations benefit from a low systemic concentration of mexiletine, which does not usually induce adverse neurological side effects. The aim of this study was, therefore, to investigate the biophysical effects of mexiletine on the L858F primary erythromelalgia NaV 1.7 mutation in vitro. EXPERIMENTAL APPROACH Human wild-type and L858F-mutated NaV 1.7 channels were expressed in HEK293A cells. Whole-cell currents were recorded by voltage-clamp techniques to characterize the effect of mexiletine on channel gating properties. KEY RESULTS While the concentration-dependent tonic block of peak currents by mexiletine was similar in wild-type and L858F channels, phasic block was more pronounced in cells transfected with the L858F mutation. Moreover, mexiletine substantially shifted the pathologically-hyperpolarized voltage-dependence of steady-state activation in L858F-mutated channels towards wild-type values and the voltage-dependence of steady-state fast inactivation was shifted to more hyperpolarized potentials, leading to an overall reduction in window currents. CONCLUSION AND IMPLICATIONS Mexiletine has a normalizing effect on the pathological gating properties of the L858F gain-of-function mutation in NaV 1.7, which, in part, might explain the beneficial effects of systemic treatment with mexiletine in patients with gain-of-function sodium channel disorders.
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Affiliation(s)
- R Cregg
- Molecular Nociception Group, Wolfson Institute for Biomedical Research, UCL, London, UK; UCL Centre for Anaesthesia, Critical Care and Pain Medicine, London, UK
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Eijkelkamp N, Linley JE, Baker MD, Minett MS, Cregg R, Werdehausen R, Rugiero F, Wood JN. Neurological perspectives on voltage-gated sodium channels. Brain 2012; 135:2585-612. [PMID: 22961543 PMCID: PMC3437034 DOI: 10.1093/brain/aws225] [Citation(s) in RCA: 248] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The activity of voltage-gated sodium channels has long been linked to disorders of neuronal excitability such as epilepsy and chronic pain. Recent genetic studies have now expanded the role of sodium channels in health and disease, to include autism, migraine, multiple sclerosis, cancer as well as muscle and immune system disorders. Transgenic mouse models have proved useful in understanding the physiological role of individual sodium channels, and there has been significant progress in the development of subtype selective inhibitors of sodium channels. This review will outline the functions and roles of specific sodium channels in electrical signalling and disease, focusing on neurological aspects. We also discuss recent advances in the development of selective sodium channel inhibitors.
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Affiliation(s)
- Niels Eijkelkamp
- Molecular Nociception Group, Wolfson Institute for Biomedical Research, University College London, Gower Street, London WC1E 6BT, UK.
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Marmura MJ. Intravenous lidocaine and mexiletine in the management of trigeminal autonomic cephalalgias. Curr Pain Headache Rep 2010; 14:145-50. [PMID: 20425204 DOI: 10.1007/s11916-010-0098-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Lidocaine and mexiletine are class 1B antiarrhythmic drugs that act on sodium channels. Lidocaine is also an important anesthetic and topical agent that is useful in the treatment of multiple pain disorders, and mexiletine is commonly used for neuropathic pain and myotonia. Both intravenous lidocaine and mexiletine are increasingly used to treat pain syndromes and appear to be particularly effective in neuropathic pain. This suggests a role for these agents in patients with headache disorders. This article describes the role of intravenous lidocaine and mexiletine in the management of headache and trigeminal autonomic cephalalgias based on the published literature to date and provides practical guidelines for their use.
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Affiliation(s)
- Michael J Marmura
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Lampert A, O'Reilly AO, Reeh P, Leffler A. Sodium channelopathies and pain. Pflugers Arch 2010; 460:249-63. [PMID: 20101409 DOI: 10.1007/s00424-009-0779-3] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Revised: 12/13/2009] [Accepted: 12/18/2009] [Indexed: 12/19/2022]
Abstract
Chronic pain often represents a severe, debilitating condition. Up to 10% of the worldwide population are affected, and many patients are poorly responsive to current treatment strategies. Nociceptors detect noxious conditions to produce the sensation of pain, and this signal is conveyed to the CNS by means of action potentials. The fast upstroke of action potentials is mediated by voltage-gated sodium channels, of which nine pore-forming alpha-subunits (Nav1.1-1.9) have been identified. Heterogeneous functional properties and distinct expression patterns denote specialized functions of each subunit. The Nav1.7 and Nav1.8 subunits have emerged as key molecules involved in peripheral pain processing and in the development of an increased pain sensitivity associated with inflammation and tissue injury. Several mutations in the SCN9A gene encoding for Nav1.7 have been identified as important cellular substrates for different heritable pain syndromes. This review aims to cover recent progress on our understanding of how biophysical properties of mutant Nav1.7 translate into an aberrant electrogenesis of nociceptors. We also recapitulate the role of Nav1.8 for peripheral pain processing and of additional sodium channelopathies which have been linked to disorders with pain as a significant component.
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Affiliation(s)
- Angelika Lampert
- Department of Physiology and Pathophysiology, Friedrich-Alexander University Erlangen-Nuremberg, Universitätsstrasse 17, 91054, Erlangen, Germany.
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Iqbal J, Bhat MI, Charoo BA, Syed WA, Sheikh MA, Bhat IN. Experience with oral mexiletine in primary erythromelalgia in children. Ann Saudi Med 2009; 29:316-8. [PMID: 19584578 PMCID: PMC2841462 DOI: 10.4103/0256-4947.55316] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Primary erythromelalgia is characterized by burning pain, redness, and warmth in the extremities. We present two cases of primary erythromelalgia both of whom presented with a history of several months of severe burning pain in both hands and feet. Both patients had received multiple pain medications with no improvement in symptoms. Pain was relieved by putting affected parts in ice cold water, which resulted in immersion injury of the affected parts. Both patients stopped taking part in school and social activities. We tried oral mexiletine, a class Ib antiarrythmic agent, in view of its reported role in various chronic painful conditions. Dramatic improvement was observed with its use. Both patients improved after several weeks of use, and there were fewer soaking episodes. We observed no adverse effects with mexilitine therapy.
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Affiliation(s)
- Javeed Iqbal
- Department of Pediatrics and Neonatology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir 190019, India.
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A case of primary erythermalgia with encephalopathy. J Neurol 2009; 256:1767-8. [DOI: 10.1007/s00415-009-5188-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2009] [Revised: 05/07/2009] [Accepted: 05/17/2009] [Indexed: 10/20/2022]
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Affiliation(s)
- L Misery
- Service de Dermatologie, Hôpital Morvan, CHU de Brest, 5, avenue Foch, 29200 Brest.
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Abstract
OBJECTIVE Erythromelalgia is a rare condition, of uncertain etiology, characterized by episodic erythema, intense burning pain and warmth of the hands and/or feet, and when chronic, associated with significant disability. The diagnosis is based on a thorough history and physical exam during a painful episode along with diagnostic testing to exclude other causes. This paper describes the unique syndrome of erythromelalgia through a case report and literature review. DESIGN Case presentation and literature review. PATIENTS A 44-year-old male with erythromelalgia. CONCLUSIONS Despite multiple treatment options, erythromelalgia is a challenging disease to effectively manage. Early recognition and treatment may offer patients the best probability of achieving remission or significant improvement.
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Affiliation(s)
- Charles J Buttaci
- Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, 30 Bergen Street, Newark, NJ 07101, USA.
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Lee MJ, Yu HS, Hsieh ST, Stephenson DA, Lu CJ, Yang CC. Characterization of a familial case with primary erythromelalgia from Taiwan. J Neurol 2007; 254:210-4. [PMID: 17294067 DOI: 10.1007/s00415-006-0328-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2005] [Accepted: 04/03/2006] [Indexed: 11/29/2022]
Abstract
Familial primary erythromelalgia is a rare autosomal dominant disease characterized by redness and painful episodes of the feet and hands, which is often triggered by heat or exercise. In this report, a Taiwanese family with the characteristic features of erythromelalgia is described. Genetic linkage studies established that the disease locus maps to human chromosome 2. Sequence analysis indicated that the disease segregates with a novel mutation in the alpha subunit of the voltage-gated sodium channel (SCN9A or Na(v)1.7). The change observed is predicted to cause the substitution of a highly conserved isoluecine 136 for a valine within the first segment of the transmembrane domain (D1S1). Using immuno-histochemistry to stain a skin biopsy specimen from the affected region, we demonstrate that there is a significant reduction in the number of small fibers.
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Affiliation(s)
- Ming-Jen Lee
- Department of Neurology, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei 100, Taiwan
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Abstract
No treatment is consistently effective in the management of patients with erythromelalgia. There is a dearth of adequate studies examining the response of erythromelalgia to treatment. Most recommendations are suggested based on case reports, small case series, and anecdotal reports. The management of erythromelalgia is difficult and frequently involves a multidisciplinary approach. An approach to management of individuals with erythromelalgia includes patient education, learning to avoid episodes, relieving discomfort of the episodes, controlling secondary and underlying factors, and use of drugs used to control erythromelalgia.
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Affiliation(s)
- Mark D P Davis
- Department of Dermatology and the Gonda Vascular Center, Mayo Clinic and Mayo Foundation, 200 First Street, SW, Rochester, MN 55905, USA.
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Drenth JPH, te Morsche RHM, Guillet G, Taieb A, Kirby RL, Jansen JBMJ. SCN9A mutations define primary erythermalgia as a neuropathic disorder of voltage gated sodium channels. J Invest Dermatol 2005; 124:1333-8. [PMID: 15955112 DOI: 10.1111/j.0022-202x.2005.23737.x] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Primary erythermalgia is a rare disorder characterized by recurrent attacks of red, warm and painful hands, and/or feet. We previously localized the gene for primary erythermalgia to a 7.94 cM region on chromosome 2q. Recently, Yang et al identified two missense mutations of the sodium channel alpha subunit SCN9A in patients with erythermalgia. The presence of voltage-gated sodium channels in sensory neurons is thought to play a crucial role in several chronic painful neuropathies. We examined four different families and two sporadic cases and detected missense sequence variants in SCN9A to be present in primary erythermalgia patients. A total of five of six mutations were located in highly conserved regions. One family with autosomal dominantly inherited erythermalgia was double heterozygous for two separate SCN9A mutations. These data establish primary erythermalgia as a neuropathic disorder and offers hope for treatment of this incapacitating painful disorder.
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Affiliation(s)
- Joost P H Drenth
- Department of Medicine, Division of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
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Dib-Hajj SD, Rush AM, Cummins TR, Hisama FM, Novella S, Tyrrell L, Marshall L, Waxman SG. Gain-of-function mutation in Nav1.7 in familial erythromelalgia induces bursting of sensory neurons. Brain 2005; 128:1847-54. [PMID: 15958509 DOI: 10.1093/brain/awh514] [Citation(s) in RCA: 344] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Erythromelalgia is an autosomal dominant disorder characterized by burning pain in response to warm stimuli or moderate exercise. We describe a novel mutation in a family with erythromelalgia in SCN9A, the gene that encodes the Na(v)1.7 sodium channel. Na(v)1.7 produces threshold currents and is selectively expressed within sensory neurons including nociceptors. We demonstrate that this mutation, which produces a hyperpolarizing shift in activation and a depolarizing shift in steady-state inactivation, lowers thresholds for single action potentials and high frequency firing in dorsal root ganglion neurons. Erythromelalgia is the first inherited pain disorder in which it is possible to link a mutation with an abnormality in ion channel function and with altered firing of pain signalling neurons.
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Affiliation(s)
- S D Dib-Hajj
- Department of Neurology, Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06510, USA
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26
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Nathan A, Rose JB, Guite JW, Hehir D, Milovcich K. Primary erythromelalgia in a child responding to intravenous lidocaine and oral mexiletine treatment. Pediatrics 2005; 115:e504-7. [PMID: 15741349 DOI: 10.1542/peds.2004-1395] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Erythromelalgia is a rare, chronic, debilitating condition characterized by redness, warmth, and severe burning pain of the distal extremities. The feet are more commonly affected than the hands. Pain is precipitated by increases in temperature and by exercise. Patients often obtain relief by immersing the affected extremity in cold water. The pain is often refractory to treatment. For many patients, multiple pain medications have been useless in achieving complete relief of pain symptoms. Previous reports of erythromelalgia among adolescents indicated prolonged relief of pain with sodium nitroprusside infusions, epidural infusions of local anesthetics, or gabapentin treatment. We present a case of an 11-year-old, white, male child with primary erythromelalgia, whose initial symptoms started in his preschool years and whose childhood was marked by escalating episodes of pain with warmth and redness of his feet, precipitated especially by increases in temperature and by activity. All conventional pain management techniques had failed to relieve our patient of his symptoms, and he obtained some relief only by soaking his affected extremities in ice water. He had experienced minimal benefit from seeing a pain psychologist, who helped him develop techniques to cope with the pain. At the time of presentation, the patient's episodes of pain had increased to 15 to 20 per day, and there was evidence of chronic immersion injury to the skin of his feet. Before his most recent hospitalization, the pain had spread to involve his hands as well. The patient was overwhelmed with anxiety and could not participate in school or social activities at the time of admission. During his current hospitalization, he did show some therapeutic response to sodium nitroprusside infusion, which unfortunately had to be discontinued because of side effects and because his family desired to leave the ICU environment, which was stressful to the patient. He also had some response to lumbar epidural infusion of local anesthetics, which could not be continued because he found the motor blockade that accompanied his analgesia intolerable. However, intravenous lidocaine infusion, with subsequent transition to oral mexiletine therapy, proved very effective in reducing the frequency and severity of the pain episodes. The patient was discharged from the hospital with oral mexiletine therapy and has been monitored at the pain management clinic. He returned to and completed school, attended summer camp, and enjoys an active happy life. He walks without precipitating pain in his feet and sleeps 9 to 10 hours every night. He has needed to soak his feet on only 4 occasions in the 6 months since his discharge from the hospital. His quality of life has improved significantly. He has shown no evidence of liver toxicity, and his mexiletine levels have been stable.
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Affiliation(s)
- Aruna Nathan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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27
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Waxman SG, Dib-Hajj SD. Erythromelalgia: A hereditary pain syndrome enters the molecular era. Ann Neurol 2005; 57:785-8. [PMID: 15929046 DOI: 10.1002/ana.20511] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
In contrast with acquired pain syndromes, molecular substrates for hereditary pain disorders have been poorly understood. Familial erythromelalgia (Weir Mitchell's disease), also known as primary erythermalgia, is an autosomal dominant disorder characterized by burning pain in the extremities in response to warm stimuli or moderate exercise. The cause of this disorder has been enigmatic, and treatment has been empirical and not very effective. Recent studies, however, have shown that familial erythromelalgia is a channelopathy caused by mutations in the gene encoding the Na(v)1.7 sodium channel which lead to altered channel function. Selective expression of Na(v)1.7 within dorsal root ganglion neurons including nociceptors (in which this channel is targeted to sensory terminals, close to impulse trigger zones) and within sympathetic ganglion neurons explains why patients experience pain but do not suffer from seizures or other manifestations of altered excitability within central nervous system neurons. Erythromelalgia is the first human disorder in which it has been possible to associate an ion channel mutation with chronic neuropathic pain. Identification of mutations within a peripheral neuron-specific sodium channel suggests the possibility of rational therapies that target the affected channel. Moreover, because some other pain syndromes, including acquired disorders, involve altered sodium channel function, erythromelalgia may emerge as a model disease that holds more general lessons about the molecular neurobiology of chronic pain.
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Affiliation(s)
- Stephen G Waxman
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06510, USA.
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28
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Jang HS, Jung D, Kim S, Jo J, Lee J, Kim M, Oh C, Kwon K. A case of primary erythromelalgia improved by mexiletine. Br J Dermatol 2004; 151:708-10. [PMID: 15377366 DOI: 10.1111/j.1365-2133.2004.06167.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sakamoto K, Karikomi Y, Kubota Y, Nakahara T, Ishii K. Characterization of mexiletine as an antagonist of beta-adrenoceptor in Chinese hamster ovary cells expressing cloned human beta-adrenoceptors. Biochem Pharmacol 2004; 67:815-22. [PMID: 15104234 DOI: 10.1016/j.bcp.2003.09.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We characterized the beta-adrenoceptor-blocking property of mexiletine, a class Ib antiarrhythmic drug, on Chinese hamster ovary (CHO) cells stably expressing cloned human beta1-, beta2-, and beta3-adrenoceptors. In radioligand binding experiments, mexiletine (10 microM-1 mM) concentration-dependently displaced the specific binding of [125I]cyanopindolol to human beta1- and beta2-adrenoceptors in the membrane fraction of the cells. High concentration (100 microM-1 mM) of mexiletine partially displaced the specific binding of [125I]cyanopindolol to human beta3-adrenoceptor. On the other hand, high concentration (300 microM and 1 mM) of lidocaine, another class Ib antiarrhythmic drug, partially displaced the specific binding of [125I]cyanopindolol to human beta1-adrenoceptor, whereas it did not affect the specific binding of [125I]cyanopindolol to human beta2- and beta3-adrenoceptors. Mexiletine (5, 50, and 500 microM) reduces basal adenosine 3',5'-cyclic monophosphate (cAMP) level and isoprenaline-induced cAMP accumulation on CHO cells stably expressing cloned human beta1- and beta2-adrenoceptors. Lidocaine (10 and 100 microM and 1 mM) tend to reduce basal cAMP level on CHO cells stably expressing cloned human beta1-adrenoceptors, whereas the drug did not reduce the isoprenaline-induced cAMP accumulation on CHO cells stably expressing cloned human beta1-, beta2-, and beta3-adrenoceptors. Mexiletine and lidocaine have no effect on forskolin (0.1, 1, and 3 microM)-induced cAMP accumulation. These results demonstrate that mexiletine blocks the binding of agonists to beta1- and beta2-adrenoceptors, and thereby attenuates the agonist-induced cAMP accumulation, and that the action of mexiletine as an antagonist of beta1- and beta2-adrenoceptors is independent of its antiarrhythmic property.
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Affiliation(s)
- Kenji Sakamoto
- Department of Molecular Pharmacology, Kitasato University School of Pharmaceutical Sciences, 9-1 Shirokane 5-chome, Minato-ku, Tokyo 108-8641, Japan.
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Abstract
No treatment is consistently effective in the management of patients with erythromelalgia. There is a dearth of adequate studies examining the response of erythromelalgia to therapy. Most recommendations are suggested based on case reports, small case series, and anecdotal reports. The management of erythromelalgia is difficult and frequently involves a multidisciplinary approach. An approach to management of individuals with erythromelalgia includes patient education, learning to avoid episodes relieving discomfort of the episodes, controlling secondary and underlying factors, and use of drugs used to control erythromelalgia.
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Affiliation(s)
- Mark D. P. Davis
- Department of Dermatology and the Gonda Vascular Center, Mayo Clinic and Mayo Foundation, 200 First Street, SW, Rochester, MN 55905, USA.
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31
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Moreno Giménez JC. ¿Qué hay de nuevo en terapéutica? ACTAS DERMO-SIFILIOGRAFICAS 2001. [DOI: 10.1016/s0001-7310(01)76445-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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32
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Abstract
Erythromelalgia is a rare condition that has remained an enigma diagnostically and therapeutically for decades. It has been assumed that erythromelalgia, which is characterized by hot, red, intensely painful feet or hands, may be the opposite of Raynaud's phenomenon. However, new research suggests that these two disorders are more similar than dissimilar. Erythromelalgia usually follows a chronic, sometimes progressive and disabling course. New evidence suggests that this may not be a disease entity at all, but a syndrome of dysfunctional vascular dynamics; recent studies demonstrate that this dysfunction is reversible in some patients. This review article presents the latest theories and successful treatments for erythromelalgia, and data from a survey of members of The Erythromelalgia Association, which was formed to provide information about erythromelalgia to doctors and patients.
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Affiliation(s)
- J S Cohen
- Department of Psychiatry, University of California, San Diego, USA.
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