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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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Pediatric Erythromelalgia and SCN9A Mutations: Systematic Review and Single-Center Case Series. J Pediatr 2019; 206:217-224.e9. [PMID: 30416015 DOI: 10.1016/j.jpeds.2018.10.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 09/07/2018] [Accepted: 10/11/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To evaluate the clinical features of erythromelalgia in childhood associated with gain-of-function SCN9A mutations that increase activity of the Nav1.7 voltage-gated sodium channel, we conducted a systematic review of pediatric presentations of erythromelalgia related to SCN9A mutations, and compared pediatric clinical presentations of symptomatic erythromelalgia, with or without SCN9A mutations. STUDY DESIGN PubMed, Embase, and PsycINFO Databases were searched for reports of inherited erythromelalgia in childhood. Clinical features, management, and genotype were extracted. Case notes of pediatric patients with erythromelalgia from the Great Ormond Street Hospital Pain Service were reviewed for clinical features, patient-reported outcomes, and treatments. Children aged over 10 years were recruited for quantitative sensory testing. RESULTS Twenty-eight publications described erythromelalgia associated with 15 different SCN9A gene variants in 25 children. Pain was severe and often refractory to multiple treatments, including nonspecific sodium channel blockers. Skin damage or other complications of cold immersion for symptomatic relief were common (60%). SCN9A mutations resulting in greater hyperpolarizing shifts in Nav1.7 sodium channels correlated with symptom onset at younger ages (P = .016). Variability in reporting, and potential publication bias toward severe cases, limit any estimations of overall prevalence. In our case series, symptoms were similar but comorbidities were more common in children with SCN9A mutations. Quantitative sensory testing revealed marked dynamic warm allodynia. CONCLUSIONS Inherited erythromelalgia in children is associated with difficult-to-manage pain and significant morbidity. Standardized reporting of outcome and management in larger series will strengthen identification of genotype-phenotype relationships. More effective long-term therapies are a significant unmet clinical need.
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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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Abstract
The low prevalence of erythromelalgia, classified as an orphan disease, poses diagnostic and therapeutic difficulties. The aim of this review is to be an update of the specialized bibliography. Erythromelalgia is an infrequent episodic acrosyndrome affecting mainly both lower limbs symmetrically with the classic triad of erythema, warmth and burning pain. Primary erythromelalgia is an autosomal dominant inherited disorder, while secondary is associated with myeloproliferative diseases, among others. In its etiopathogenesis, there are neural and vascular abnormalities that can be combined. The diagnosis is based on exhaustive clinical history and physical examination. Complications are due to changes in the skin barrier function, ischemia and compromise of cutaneous nerves. Because of the complexity of its pathogenesis, erythromelalgia should always be included in the differential diagnosis of conditions that cause chronic pain and/or peripheral edema. The prevention of crisis is based on a strict control of triggers and promotion of preventive measures. Since there is no specific and effective treatment, control should focus on the underlying disease. However, there are numerous topical and systemic therapies that patients can benefit from.
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Kist AM, Sagafos D, Rush AM, Neacsu C, Eberhardt E, Schmidt R, Lunden LK, Ørstavik K, Kaluza L, Meents J, Zhang Z, Carr TH, Salter H, Malinowsky D, Wollberg P, Krupp J, Kleggetveit IP, Schmelz M, Jørum E, Lampert A, Namer B. SCN10A Mutation in a Patient with Erythromelalgia Enhances C-Fiber Activity Dependent Slowing. PLoS One 2016; 11:e0161789. [PMID: 27598514 PMCID: PMC5012686 DOI: 10.1371/journal.pone.0161789] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 08/11/2016] [Indexed: 11/18/2022] Open
Abstract
Gain-of-function mutations in the tetrodotoxin (TTX) sensitive voltage-gated sodium channel (Nav) Nav1.7 have been identified as a key mechanism underlying chronic pain in inherited erythromelalgia. Mutations in TTX resistant channels, such as Nav1.8 or Nav1.9, were recently connected with inherited chronic pain syndromes. Here, we investigated the effects of the p.M650K mutation in Nav1.8 in a 53 year old patient with erythromelalgia by microneurography and patch-clamp techniques. Recordings of the patient’s peripheral nerve fibers showed increased activity dependent slowing (ADS) in CMi and less spontaneous firing compared to a control group of erythromelalgia patients without Nav mutations. To evaluate the impact of the p.M650K mutation on neuronal firing and channel gating, we performed current and voltage-clamp recordings on transfected sensory neurons (DRGs) and neuroblastoma cells. The p.M650K mutation shifted steady-state fast inactivation of Nav1.8 to more hyperpolarized potentials and did not significantly alter any other tested gating behaviors. The AP half-width was significantly broader and the stimulated action potential firing rate was reduced for M650K transfected DRGs compared to WT. We discuss the potential link between enhanced steady state fast inactivation, broader action potential width and the potential physiological consequences.
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Affiliation(s)
- Andreas M. Kist
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Dagrun Sagafos
- Section of Clinical Neurophysiology, Department of Neurology, Oslo University Hospital -Rikshospitalet, Oslo, Norway
| | | | - Cristian Neacsu
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Esther Eberhardt
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Department of Anesthesiology, Friedrich-Alexander-Universität Erlangen-Nuremberg, Erlangen, Germany
| | - Roland Schmidt
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
| | - Lars Kristian Lunden
- Section of Clinical Neurophysiology, Department of Neurology, Oslo University Hospital -Rikshospitalet, Oslo, Norway
| | - Kristin Ørstavik
- Section of Clinical Neurophysiology, Department of Neurology, Oslo University Hospital -Rikshospitalet, Oslo, Norway
| | - Luisa Kaluza
- Institute of Physiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Jannis Meents
- Institute of Physiology, RWTH Aachen University Hospital, Aachen, Germany
| | | | | | | | | | | | | | - Inge Petter Kleggetveit
- Section of Clinical Neurophysiology, Department of Neurology, Oslo University Hospital -Rikshospitalet, Oslo, Norway
| | - Martin Schmelz
- Department of Anesthesiology Mannheim, Heidelberg University, Mannheim, Germany
| | - Ellen Jørum
- Section of Clinical Neurophysiology, Department of Neurology, Oslo University Hospital -Rikshospitalet, Oslo, Norway
- * E-mail: (EJ); (AL); (BN)
| | - Angelika Lampert
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Institute of Physiology, RWTH Aachen University Hospital, Aachen, Germany
- * E-mail: (EJ); (AL); (BN)
| | - Barbara Namer
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Department of Anesthesiology Mannheim, Heidelberg University, Mannheim, Germany
- * E-mail: (EJ); (AL); (BN)
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McDonnell A, Schulman B, Ali Z, Dib-Hajj SD, Brock F, Cobain S, Mainka T, Vollert J, Tarabar S, Waxman SG. Inherited erythromelalgia due to mutations inSCN9A:natural history, clinical phenotype and somatosensory profile. Brain 2016; 139:1052-65. [DOI: 10.1093/brain/aww007] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 12/04/2015] [Indexed: 12/12/2022] Open
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Chuquilin M, Dhand UK. Erythromelalgia-like presentation of chronic acquired demyelinating polyneuropathy in a setting of past alcohol abuse. Neuromuscul Disord 2016; 26:176-80. [DOI: 10.1016/j.nmd.2015.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 09/22/2015] [Accepted: 11/16/2015] [Indexed: 10/22/2022]
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