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Meduri A, Oliverio GW, Valastro A, Azzaro C, Camellin U, Franchina F, Inferrera L, Roszkowska A, Aragona P. Neurotrophic Keratopathy in Systemic Diseases: A Case Series on Patients Treated With rh-NGF. Front Med (Lausanne) 2022; 9:920688. [PMID: 35707524 PMCID: PMC9189296 DOI: 10.3389/fmed.2022.920688] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose To evaluate the prevalence, clinical ocular presentation and corneal healing in moderate and severe neurotrophic keratopathy (NK) caused by systemic diseases and treated with rh-NGF. Setting Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Ophthalmology Clinic, University of Messina, Italy. Design Retrospective observational study of case series. Materials and Methods In this retrospective observational study 11 patients (five female and six males) aged from 24 to 88 years (55.4 ± 21.3 years) with moderate and severe NK caused by systemic diseases were enrolled. The VAS questionnaire was dispensed. The ocular examination comprised slit lamp evaluation, ocular surface assessment with Keratograph 5M (Oculus, Germany), corneal sensitivity with Cochet-Bonnet esthesiometer (Lunneaux, France) and corneal thickness measurement with AC-OCT (DRI, Triton, Topcon, Japan). The underlying systemic causes of NK were determined. Results The main cause of NK was post-neuroma surgery (36%), followed by diabetes (18%). The remaining causes were rheumatoid arthritis (9%), post-traumatic (9%), post-surgery (9%), atopia (9%), Graves' disease (9%). Seven eyes presented severe grade of NK with corneal ulcer and in four a moderate grade was registered. The rh-NGF (Cenegermin) was administered with a standard protocol one drop six times daily for 8 weeks. The complete healing of all corneal defects was registered at the end of the treatment. Conclusions The post-neuroma surgery was the most common cause of NK and severe grade was clinically more represented. The rh-NGF proved effective to promote corneal recovery with all defects healed after the treatment.
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Affiliation(s)
- Alessandro Meduri
- Department of Biomedical Sciences, Ophthalmology Clinic, University of Messina, Messina, Italy
| | - Giovanni William Oliverio
- Department of Biomedical Sciences, Ophthalmology Clinic, University of Messina, Messina, Italy
- *Correspondence: Giovanni William Oliverio
| | - Antonio Valastro
- Department of Biomedical Sciences, Ophthalmology Clinic, University of Messina, Messina, Italy
| | - Claudia Azzaro
- Department of Biomedical Sciences, Ophthalmology Clinic, University of Messina, Messina, Italy
| | - Umberto Camellin
- Department of Biomedical Sciences, Ophthalmology Clinic, University of Messina, Messina, Italy
| | - Francesco Franchina
- Department of Biomedical Sciences, Ophthalmology Clinic, University of Messina, Messina, Italy
| | - Leandro Inferrera
- Department of Medical, Surgical Sciences and Health, Eye Clinic, University of Trieste, Trieste, Italy
| | - Anna Roszkowska
- Department of Biomedical Sciences, Ophthalmology Clinic, University of Messina, Messina, Italy
- Department of Ophthalmology, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Kraków, Poland
| | - Pasquale Aragona
- Department of Biomedical Sciences, Ophthalmology Clinic, University of Messina, Messina, Italy
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Hanatleh OM, Kofahi NK, Aburahma SK, Bintareef EM, Al-Bashtawy M, Alkhawaldeh A, Ibnian AM. A 5-Year-Old Palestinian Bedouin Girl with Repeated Self-Induced Injuries to the Digits, a Diagnosis of Congenital Insensitivity to Pain, and Anhidrosis. Am J Case Rep 2021; 22:e933486. [PMID: 34732685 PMCID: PMC8579061 DOI: 10.12659/ajcr.933486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Congenital insensitivity to pain with anhidrosis (CIPA), also referred to as hereditary sensory and autonomic neuropathy type IV, is a rare autosomal recessive disease caused by mutations in the NTRK1 gene. The inability to feel pain and temperature often leads to repeated severe and unintentional self-inflicted injuries; these can result in severe complications, as patients heal slowly from skin and bone injuries. This case report describes a 5-year-old Palestinian girl with self-inflicted injury to the digits, a dislocated distal inter-phalangeal joint of the left big toe, and a diagnosis of CIPA. CASE REPORT A 5-year-old girl, a daughter of related Palestinian Bedouin parents, presented with a chronic unhealed wound over the planter surface of the left foot. Painless repetitive minor traumata over the same area badly affected wound healing and this led to wound dehiscence and dislocation of the distal inter-phalangeal joint of the left big toe. Surgical fixation of the dislocated joint along with intravenous antibiotics and close follow-up resulted in eventual improvement and near complete wound healing despite the obviously slow healing process. The girl also displayed evidence of unintentional self-inflicted injury, which within the overall clinical context warranted a clinical suspicion of CIPA. This was confirmed by genetic testing for the presence of a homozygous frameshift mutation in the NTRK1 gene (c.1842_1843insT; p.Pro615Serfs*12). CONCLUSIONS This case report shows that a physician should have a low threshold of suspicion to investigate for CIPA when managing children with multiple unintentional self-inflicted injuries, anhidrosis, and pain insensitivity, mainly through genetic testing to detect mutations in the NTRK1 gene.
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Affiliation(s)
- Omar M Hanatleh
- Department of Orthopedics, Al-Safa Specialized Hospital, Jarash, Jordan
| | - Noran K Kofahi
- Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Samah K Aburahma
- Department of Pediatrics, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | | | | | | | - Ali M Ibnian
- Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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Elsana B, Gradstein L, Imtirat A, Yagev R, Barrett C, Ling G, Abu Tailakh M, Baidousi A, Tsumi E. Ocular manifestations of congenital insensitivity to pain: a long-term follow-up. Br J Ophthalmol 2021; 106:1217-1221. [PMID: 33753408 DOI: 10.1136/bjophthalmol-2020-317464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 02/28/2021] [Accepted: 03/06/2021] [Indexed: 01/02/2023]
Abstract
AIM To describe ocular manifestations in children with congenital insensitivity to pain with and without anhidrosis (CIPA and CIP). METHODS We reviewed records of eye examinations of 39 children diagnosed with CIPA or CIP. We collected clinical data, with particular attention to ocular surface findings. Corneal sensitivity was tested by presence of a blink reflex upon touching the cornea. Statistical analysis assessed differences in manifestations between the two conditions, and relationships among corneal sensitivity, presence of corneal opacities and visual acuity (VA). RESULTS CIPA was diagnosed in 32 children and CIP in 7. The median follow-up periods were 50 months (CIPA group) and 94 months (CIP group). Corneal opacities were present in 23% of CIPA eyes and in 57% of CIP eyes. A blink reflex was positive in 52% of CIPA eyes and in 33% of CIP eyes. We recorded VA ≥20/25 in 36% of CIPA eyes, whereas all patients with CIP had VA ≤20/30. For the whole cohort, we found a negative correlation between a preserved blink reflex and the presence of corneal opacities, and a positive correlation between a preserved blink reflex and VA ≥20/25. CONCLUSION Children with congenital insensitivity to pain are prone to develop corneal scarring. Patients with CIP tend to have more severe ocular surface disease than those with CIPA, probably due to more prevalent loss of corneal sensation. In both groups, a preserved blink reflex correlated with good vision. Affected children should have close follow-up to promptly treat ocular surface disease and prevent vision loss.
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Affiliation(s)
- Baker Elsana
- Ophthalmology Department, Soroka University Medical Center, Clalit Health Services, Beer Sheva, Israel .,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Libe Gradstein
- Ophthalmology Department, Soroka University Medical Center, Clalit Health Services, Beer Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Ahed Imtirat
- Ophthalmology Department, Soroka University Medical Center, Clalit Health Services, Beer Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Ronit Yagev
- Ophthalmology Department, Soroka University Medical Center, Clalit Health Services, Beer Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Chiya Barrett
- Ophthalmology Department, Soroka University Medical Center, Clalit Health Services, Beer Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Galina Ling
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.,Pediatric Ambulatory Services, Saban Pediatric Medical Center for Israel, Soroka University Medical Center, Beer Sheva, Israel
| | - Muhammad Abu Tailakh
- Recanati School for Community Health Professions, Department of Nursing, Ben-Gurion University of the Negev Faculty of Health Sciences and Soroka University Medical Center, Beer Sheva, Israel
| | - Amjad Baidousi
- Ophthalmology Department, Soroka University Medical Center, Clalit Health Services, Beer Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Erez Tsumi
- Ophthalmology Department, Soroka University Medical Center, Clalit Health Services, Beer Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
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López-Cortés A, Zambrano AK, Guevara-Ramírez P, Echeverría BA, Guerrero S, Cabascango E, Pérez-Villa A, Armendáriz-Castillo I, García-Cárdenas JM, Yumiceba V, Pérez-M G, Leone PE, Paz-y-Miño C. Clinical, genomics and networking analyses of a high-altitude native American Ecuadorian patient with congenital insensitivity to pain with anhidrosis: a case report. BMC Med Genomics 2020; 13:113. [PMID: 32807182 PMCID: PMC7437939 DOI: 10.1186/s12920-020-00764-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Congenital insensitivity to pain with anhidrosis (CIPA) is an extremely rare autosomal recessive disorder characterized by insensitivity to pain, inability to sweat and intellectual disability. CIPA is caused by mutations in the neurotrophic tyrosine kinase receptor type 1 gene (NTRK1) that encodes the high-affinity receptor of nerve growth factor (NGF). CASE PRESENTATION Here, we present clinical and molecular findings in a 9-year-old girl with CIPA. The high-altitude indigenous Ecuadorian patient presented several health problems such as anhidrosis, bone fractures, self-mutilation, osteochondroma, intellectual disability and Riga-Fede disease. After the mutational analysis of NTRK1, the patient showed a clearly autosomal recessive inheritance pattern with the pathogenic mutation rs763758904 (Arg602*) and the second missense mutation rs80356677 (Asp674Tyr). Additionally, the genomic analysis showed 69 pathogenic and/or likely pathogenic variants in 46 genes possibly related to phenotypic heterogeneity, including the rs324420 variant in the FAAH gene. The gene ontology enrichment analysis showed 28 mutated genes involved in several biological processes. As a novel contribution, the protein-protein interaction network analysis showed that NTRK1, SPTBN2 and GRM6 interact with several proteins of the pain matrix involved in the response to stimulus and nervous system development. CONCLUSIONS This is the first study that associates clinical, genomics and networking analyses in a Native American patient with consanguinity background in order to better understand CIPA pathogenesis.
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Affiliation(s)
- Andrés López-Cortés
- Centro de Investigación Genética y Genómica. Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Mariscal Sucre Avenue, 170129 Quito, Ecuador
- Latin American Network for Implementation and Validation of Clinical Pharmacogenomics Guidelines (RELIVAF-CYTED), Madrid, Spain
| | - Ana Karina Zambrano
- Centro de Investigación Genética y Genómica. Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Mariscal Sucre Avenue, 170129 Quito, Ecuador
| | - Patricia Guevara-Ramírez
- Centro de Investigación Genética y Genómica. Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Mariscal Sucre Avenue, 170129 Quito, Ecuador
| | - Byron Albuja Echeverría
- Hospital San Luis de Otavalo, Ministerio de Salud Pública, Antonio José de Sucre Avenue, 100201 Otavalo, Ecuador
| | - Santiago Guerrero
- Centro de Investigación Genética y Genómica. Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Mariscal Sucre Avenue, 170129 Quito, Ecuador
| | - Eliana Cabascango
- Sistemas Médicos (SIME), Universidad San Francisco de Quito, Interoceánica Avenue and Chimborazo, 170902 Cumbayá, Ecuador
| | - Andy Pérez-Villa
- Centro de Investigación Genética y Genómica. Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Mariscal Sucre Avenue, 170129 Quito, Ecuador
| | - Isaac Armendáriz-Castillo
- Centro de Investigación Genética y Genómica. Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Mariscal Sucre Avenue, 170129 Quito, Ecuador
| | - Jennyfer M. García-Cárdenas
- Centro de Investigación Genética y Genómica. Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Mariscal Sucre Avenue, 170129 Quito, Ecuador
| | - Verónica Yumiceba
- Centro de Investigación Genética y Genómica. Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Mariscal Sucre Avenue, 170129 Quito, Ecuador
| | | | - Paola E. Leone
- Centro de Investigación Genética y Genómica. Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Mariscal Sucre Avenue, 170129 Quito, Ecuador
| | - César Paz-y-Miño
- Centro de Investigación Genética y Genómica. Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Mariscal Sucre Avenue, 170129 Quito, Ecuador
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Suresh B, Reddy V, Kurth I, Jagadeesh S. A Child Presenting with Recurrent Corneal Ulcers: Hereditary Sensory and Autonomic Neuropathy IV (HSAN IV). Neuroophthalmology 2019; 43:310-312. [DOI: 10.1080/01658107.2018.1506937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/24/2018] [Accepted: 07/28/2018] [Indexed: 10/28/2022] Open
Affiliation(s)
- Beena Suresh
- Department of Clinical Genetics, Mediscan Systems, Chennai, India
| | - Vaishnavi Reddy
- Department of Clinical Genetics, Mediscan Systems, Chennai, India
| | - Ingo Kurth
- Institut für Humangenetik, der RWTH Aachen, Germany
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Isogawa N, Ito K, Lee J, Ikeda M, Ishikawa M, Baba Y. A case of congenital insensitivity to pain with anhidrosis with sensitivity reactions to the electric pulp test. Pediatric Dental Journal 2017; 27:101-4. [DOI: 10.1016/j.pdj.2016.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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7
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Varma AV, McBride L, Marble M, Tilton A. Congenital insensitivity to pain and anhidrosis: Case report and review of findings along neuro-immune axis in the disorder. J Neurol Sci 2016; 370:201-210. [DOI: 10.1016/j.jns.2016.09.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/30/2016] [Accepted: 09/20/2016] [Indexed: 12/19/2022]
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8
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Pérez-López LM, Cabrera-González M, Gutiérrez-de la Iglesia D, Ricart S, Knörr-Giménez G. Update Review and Clinical Presentation in Congenital Insensitivity to Pain and Anhidrosis. Case Rep Pediatr 2015; 2015:589852. [PMID: 26579324 DOI: 10.1155/2015/589852] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 09/14/2015] [Accepted: 09/16/2015] [Indexed: 11/18/2022] Open
Abstract
Introduction. Congenital insensitivity to pain and anhidrosis (CIPA) or hereditary sensory and autonomic neuropathy type IV is an extremely rare syndrome. Three clinical findings define the syndrome: insensitivity to pain, impossibility to sweat, and mental retardation. This pathology is caused by a genetic mutation in the NTRK1 gene, which encodes a tyrosine receptor (TrkA) for nerve growth factor (NGF). Methods. The consultation of a child female in our center with CIPA and a tibia fracture in pseudoarthrosis encouraged us to carefully review literature and examine the therapeutic possibilities.
A thorough review of literature published in Pubmed was done about CIPA and other connected medical issues mentioned in the paper. Conclusions. The therapeutic approach of CIPA remains unclear. The preventive approach remains the only possible treatment of CIPA. We propose two new important concepts in the therapeutic approach for these patients: (1) early surgical treatment for long bone fractures to prevent pseudoarthrosis and to allow early weight bearing, decreasing the risk of further osteopenia, and (2) bisphosphonates to avoid the progression of osteopenia and to reduce the number of consecutive fractures.
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Mantelli F, Nardella C, Tiberi E, Sacchetti M, Bruscolini A, Lambiase A. Congenital Corneal Anesthesia and Neurotrophic Keratitis: Diagnosis and Management. Biomed Res Int 2015; 2015:805876. [PMID: 26451380 DOI: 10.1155/2015/805876] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 07/29/2015] [Indexed: 11/30/2022]
Abstract
Neurotrophic keratitis (NK) is a rare degenerative disease of the cornea caused by an impairment of corneal sensory innervation, characterized by decreased or absent corneal sensitivity resulting in epithelial keratopathy, ulceration, and perforation. The aetiopathogenesis of corneal sensory innervation impairment in children recognizes the same range of causes as adults, although they are much less frequent in the pediatric population. Some extremely rare congenital diseases could be considered in the aetiopathogenesis of NK in children. Congenital corneal anesthesia is an extremely rare condition that carries considerable diagnostic and therapeutic problems. Typically the onset is up to 3 years of age and the cornea may be affected in isolation or the sensory deficit may exist as a component of a congenital syndrome, or it may be associated with systemic somatic anomalies. Accurate diagnosis and recognition of risk factors is important for lessening long-term sequelae of this condition. Treatment should include frequent topical lubrication and bandage corneal or scleral contact lenses. Surgery may be needed in refractory cases. The purpose of this review is to summarize and update data available on congenital causes and treatment of corneal hypo/anesthesia and, in turn, on congenital NK.
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Iorio ML, Barbour JR. Recurrent digital infections and osteomyelitis in monozygotic twins with congenital analgesia and compulsive onychophagia. J Child Neurol 2014; 29:962-4. [PMID: 23549047 DOI: 10.1177/0883073813482973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 02/26/2013] [Indexed: 11/15/2022]
Abstract
Congenital insensitivity to pain is a rare sensory neuropathy that manifests with multiple and recurrent injuries secondary to a lack of negative pain stimuli. When present with compulsive onychophagia, prompt recognition and behavioral management to prevent chronic digital infection or amputation is imperative. We present the case of two 7 year-old monozygotic twins that presented with congenital insensitivity to pain and compulsive onychophagia without directed parental counseling or behavioral modification strategies. The presenting child was noted to have an acute digital felon and osteomyelitis of several distal phalanges, and the sister had a similar history with distal phalangeal amputations. The occurrence of these overlapping disorders in monozygotic twins has not been previously reported, however, patient and parental education with behavioral modifications of injurious and compulsive behavior is the cornerstone of management. In addition, we have provided a review of the diagnosis for clinical differentiation.
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Affiliation(s)
- Matthew L Iorio
- Department of Plastic Surgery, Georgetown University Hospital, Washington, DC, USA
| | - John R Barbour
- Department of Plastic Surgery, Georgetown University Hospital, Washington, DC, USA
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John D, Thomas M, Jacob P. Neurotrophic Keratitis and Congenital Insensitivity to Pain With Anhidrosis—A Case Report With 10-Year Follow-up. Cornea 2011; 30:100-2. [DOI: 10.1097/ico.0b013e3181e458e4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Iijima M, Haga N. Evaluation of nonnociceptive sensation in patients with congenital insensitivity to pain with anhidrosis. Childs Nerv Syst 2010; 26:1085-9. [PMID: 20013280 DOI: 10.1007/s00381-009-1057-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2009] [Accepted: 11/17/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE Congenital insensitivity to pain with anhidrosis (CIPA) is a rare, autosomal recessive disorder characterized by lack of pain and thermal sensation, anhidrosis, thermodysregulation, and mental retardation. Although nonnociceptive sensation, which is mediated by large-caliber myelinated Abeta fibers, is reported to be normal in CIPA patients, precise clinical assessments of this type of sensation have yet to be performed. The aim of this study was to evaluate peripheral sensory nerve function, including senses of touch/pressure, vibration, joint position, and two-point discrimination, in patients with CIPA by basic clinical neurological examination. METHODS We examined touch/pressure sense, deep senses (vibration, joint proprioception), and two-point discrimination in 12 patients with CIPA (six males and six females aged 11-44) and 12 age- and sex-matched healthy controls. Touch/pressure sense was examined with Semmes-Weinstein monofilaments, vibration sense with a tuning fork, and two-point discrimination with a vernier caliper. Joint proprioception was assessed through subject recognition of passive movement of the great toe. RESULTS Perception thresholds of touch/pressure, vibration, and two-point discrimination were significantly higher (p < 0.05), and proprioception sensitivity was significantly lower (p < 0.05) in CIPA patients than in the healthy controls. CONCLUSIONS Our findings suggest that CIPA patients suffer from more widespread disturbances of sensation than has been previously recognized. Impairment may not be restricted to the types of sensation conducted by peripheral sensory Adelta and C fibers.
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Zlotnik A, Gruenbaum SE, Rozet I, Zhumadilov A, Shapira Y. Risk of aspiration during anesthesia in patients with congenital insensitivity to pain with anhidrosis: case reports and review of the literature. J Anesth 2010; 24:778-82. [PMID: 20632040 DOI: 10.1007/s00540-010-0985-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2010] [Accepted: 06/17/2010] [Indexed: 11/24/2022]
Abstract
Congenital insensitivity to pain with anhidrosis (CIPA) is a rare autosomal recessive disease, characterized by episodes of unexplained fever, anhidrosis, pain insensitivity despite intact tactile perception, self-mutilating behavior, mental retardation, and autonomic nervous system (ANS) abnormalities. We present a case series of three patients with CIPA who underwent semielective orthopedic surgery under general anesthesia complicated by intraoperative regurgitation, and subsequent aspiration in two of the three cases. All three patients were nil per os (NPO) for at least 8 h prior to surgery. Two patients had their airways maintained with a laryngeal mask airway (LMA), and one patient had an endotracheal tube (ETT). The patients with an LMA suffered aspiration of gastric contents and subsequently developed hypoxic cardiac arrest. Although the patient with an ETT in situ regurgitated intraoperatively, the presence of the ETT prevented aspiration and any further potential complications. We review the perioperative complications typically observed in patients with CIPA and discuss the risks of using an LMA in these patients. We recommend that patients with CIPA always should be considered as having a "full stomach", regardless of the duration of their NPO status, due to their coexisting ANS abnormalities. Therefore, rapid-sequence induction with an ETT should be utilized for the anesthetic management in every patient with CIPA.
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Affiliation(s)
- Alexander Zlotnik
- Department of Anesthesiology and Critical Care, Soroka Medical Center, Ben-Gurion University of the Negev, 84105 Beer-Sheva, Israel.
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Mimura T, Amano S, Fukuoka S, Honda N, Arita R, Ochiai M, Yanagisawa M, Usui T, Ono K, Araki F, Yamagami S, Araie M, Awaya Y. In VivoConfocal Microscopy of Hereditary Sensory and Autonomic Neuropathy. Curr Eye Res 2009; 33:940-5. [DOI: 10.1080/02713680802450992] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Abnormalities of the ocular surface can be acquired or inherited disorders of the central nervous system. Loss of neural stimulation from the sensory division of the trigeminal nerve or from the autonomic nervous system can have devastating consequences on corneal epithelial wound healing and the precorneal tear film, leading to decreased vision. The pathogenesis of neurotrophic keratopathy is reviewed, and treatment modalities are recommended.
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Affiliation(s)
- Kenneth Mark Goins
- Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA.
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Abstract
Congenital corneal anesthesia is a rare clinical entity that poses a diagnostic dilemma, particularly in the pediatric age group. The sensory deficit may be confined to the cornea, or extend to other divisions of the trigeminal nerve. The sensory deficit may occur as an isolated abnormality, as part of a complex neurological syndrome, or it may occur in association with multiple somatic abnormalities and congenital insensitivity to pain. This condition usually presents between the ages of 8 to 12 months. Poor vision, photophobia, conjunctival injection, and corneal ulceration in the absence of pain and distress in a child should alert the clinician to the possibility of anesthetic cornea. In the early stages of presentation, punctuate keratopathy is the main feature, which may progress to non-healing persistent corneal epithelial defects. This stage may progress to acute corneal lysis and perforation. In most patients, conservative approaches such as copious lubrication, prevention of self-harm and cautious use of bandage contact lenses are effective in preventing progressive corneal damage. Tarsorrhapy is effective in promoting epithelial healing and permanent lateral tarsorraphy may prevent further development of epithelial defects. Amniotic membrane graft may be considered in order to improve epithelial healing. Corneal grafts carry a poor prognosis. Accurate initial diagnosis, evaluation, and proper management are paramount to prevent visual loss due to long-term complications of corneal anesthesia. This review of the literature outlines the problems and approaches in diagnosis, evaluation, and management of this rare condition.
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Affiliation(s)
- K Ramaesh
- Tennent Institute of Ophthalmology, Gartnaval General Hospital, Glasgow, United Kingdom
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Amano S, Fukuoka S, Usui T, Honda N, Ideta R, Ochiai M, Yamagami S, Araie M, Awaya Y. Ocular manifestations of congenital insensitivity to pain with anhidrosis. Am J Ophthalmol 2006; 141:472-7. [PMID: 16490492 DOI: 10.1016/j.ajo.2005.10.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2005] [Revised: 10/11/2005] [Accepted: 10/11/2005] [Indexed: 11/20/2022]
Abstract
PURPOSE To describe ocular manifestations in Japanese patients with congenital insensitivity to pain with anhidrosis (CIPA), focusing particularly on the status of the ocular surface. DESIGN Observational case series. METHODS Eighteen patients with CIPA underwent applicable ophthalmologic examinations, including visual acuity, refraction, slit-lamp examination, fundus examination, tear breakup time, Schirmer 1 test, corneal sensitivity, and corneal topography. RESULTS Superficial punctate keratopathy (SPK) was observed at the interpalpebral area in 23 (64%) of 36 eyes. Corneal opacity was observed in three eyes (8.3%). Tear breakup time was below the lower limit of the normal range in all examined eyes, and the value of Schirmer 1 test was above the lower limit of the normal range in most of the examined eyes. CONCLUSIONS Superficial punctate keratopathy is observed in most cases of CIPA, which might predispose patients to corneal infection. Investigation of dry eye in patients with CIPA will provide unique opportunities to explore the critical roles of the autonomic sympathetic nervous system as well as the sensory nervous system in the physiology of tear production.
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Affiliation(s)
- Shiro Amano
- Department of Ophthalmology, Tokyo University Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
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Rozentsveig V, Katz A, Weksler N, Schwartz A, Schilly M, Klein M, Gurman GM. The anaesthetic management of patients with congenital insensitivity to pain with anhidrosis. Paediatr Anaesth 2004; 14:344-8. [PMID: 15078381 DOI: 10.1046/j.1460-9592.2003.01235.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Congenital insensitivity to pain with anhidrosis (CIPA, or hereditary sensory and autonomic neuropathy type IV) is a rare, autosomal recessive disease, related to a mutation in the TrkA gene, characterized by inability to sweat, insensitivity to pain and recurrent episodes of hyperpyrexia. There are two Bedouin tribes in Israel with different mutations of the TrkA gene: one in the southern region and the other in the northern region. The Soroka University Medical Center is the referral centre for the entire southern region of Israel. One in 4500 anaesthesia cases involves a patient with CIPA. METHODS We reviewed 40 anaesthesia records of 20 patients with CIPA for anaesthetic technique and incidence of side-effects. RESULTS Sixteen patients developed complications in the immediate perioperative period: mild hypothermia in one patient and cardiovascular events in 15 others with one case of cardiac arrest. These complications were unrelated to the anaesthetic drug administered. There were no events of hyperthermia or postoperative nausea. CONCLUSIONS Cardiovascular complications following anaesthesia are common in patients with the southern Israel variant of CIPA. Hyperthermia, previously recognized as a major concern in patients with congenital insensitivity to pain with anhydrous, was not seen in our patients. We conclude that cardiovascular involvement is frequently encountered in CIPA patients following anaesthesia and is the major concern in their anaesthetic management.
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Affiliation(s)
- V Rozentsveig
- Division of Anesthesiology and Critical Care Medicine, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
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Escard E, Barret L. Sévices à des enfants ou insensibilité congénitale à la douleur? Paediatr Child Health 2003; 8:151-4. [DOI: 10.1093/pch/8.3.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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