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Fernandez-Marta B, Abalo-Lojo JM, Arias M, Gonzalez F. Ross Syndrome in a 37-Year-Old Woman. J Neuroophthalmol 2024; 44:e405-e407. [PMID: 37389957 DOI: 10.1097/wno.0000000000001917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Affiliation(s)
- Beatriz Fernandez-Marta
- Ophthalmology Department and IDIS (BF-M, JMA-L, FG), and Neurology Department (MA), Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain; and CIMUS (FG), University of Santiago de Compostela, Santiago de Compostela, Spain
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Mourad F, Giudice A, Maritati G, Maselli F, Kranenburg R, Taylor A, Kerry R, Hutting N. A guide to identify cervical autonomic dysfunctions (and associated conditions) in patients with musculoskeletal disorders in physical therapy practice. Braz J Phys Ther 2023; 27:100495. [PMID: 37075598 DOI: 10.1016/j.bjpt.2023.100495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 09/24/2022] [Accepted: 03/06/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Differential diagnosis is a hot topic in physical therapy, especially for those working in a direct access setting dealing with neck pain and its associated disorders. All international guidelines agree in recommending to first rule out non-musculoskeletal pathologies as the cause of signs and symptoms in the patient. Although the autonomic nervous system (ANS) has a crucial role and is also involved in pain conditions, coverage of it in neuroscience textbooks and educational programmes is limited and most healthcare professionals are unfamiliar with it. Although autonomic conditions are benign in nature, they are clinically of great importance as they may be a 'red flag' warning of an injury along the sympathetic pathway. Therefore, sound knowledge of the ANS system is essential for clinicians. OBJECTIVE To develop physical therapists' knowledge of and confidence in understanding cervical ANS function and dysfunction, thus enhancing clinical reasoning skills and the pattern recognition process, and performing and interpreting objective examinations. METHODS This master class provides an introductory guide and essential knowledge to facilitate clinicians to understand cervical autonomic dysfunctions and their clinical evaluation. The optimal referral method is also handled. CONCLUSIONS Gaining knowledge and understanding of the ANS, its function, its dysfunction, and the related clinical manifestations is likely to lead to a decision-making process driven by 'science and conscience'. This will empower physical therapists to be aware of subtle clues that may be offered by patients during the interview and history intake leading to the appropriate physical examination and triage.
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Affiliation(s)
- Firas Mourad
- Department of Physical Therapy, LUNEX International University of Health, Exercise and Sports, Differdange, Luxembourg; Luxembourg Health & Sport Sciences Research Institute A.s.b.l., Differdange, Luxembourg
| | - Andrea Giudice
- Department of Physical Therapy, Poliambulatorio Physio Power, Brescia, Italy
| | - Giorgio Maritati
- Department of Physical Therapy, Poliambulatorio Physio Power, Brescia, Italy
| | - Filippo Maselli
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy; Sovrintendenza Sanitaria Regionale Puglia INAIL, Bari, Italy
| | - Rik Kranenburg
- Healthy Ageing, Allied Health Care and Nursing Research Group, Hanze University of Applied Sciences, Groningen, the Netherlands
| | - Alan Taylor
- Faculty of Medicine and Health Sciences, School of Health Sciences, University of Nottingham, UK
| | - Roger Kerry
- Faculty of Medicine and Health Sciences, School of Health Sciences, University of Nottingham, UK
| | - Nathan Hutting
- Department of Occupation and Health, School of Organisation and Development, HAN University of Applied Sciences, Nijmegen, the Netherlands.
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Abstract
AbstractDisorders of sudomotor function are common and diverse in their presentations. Hyperhidrosis or hypohidrosis in generalized or regional neuroanatomical patterns can provide clues to neurologic localization and inform neurologic diagnosis. Conditions that impair sudomotor function include small fiber peripheral neuropathy, sudomotor neuropathy, myelopathy, α-synucleinopathies, autoimmune autonomic ganglionopathy, antibody-mediated hyperexcitability syndromes, and a host of medications. Particularly relevant to neurologic practice is the detection of postganglionic sudomotor deficits as a diagnostic marker of small fiber neuropathies. Extensive anhidrosis is important to recognize, as it not only correlates with symptoms of heat intolerance but may also place the patient at risk for heat stroke when under conditions of heat stress. Methods for assessing sudomotor dysfunction include the thermoregulatory sweat test, the quantitative sudomotor axon reflex test, silicone impressions, and the sympathetic skin response.
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Abstract
The autonomic nervous system has widespread innervation to nearly every organ system in the body. In order to understand the basics of autonomic function, knowledge of the neuroanatomy of the autonomic nervous system is necessary. Frequently considered to control the "fight or flight" and "rest and digest" functions, the autonomic nervous system has an intricate network of connections to finely tune the systemic response to nearly any situation. Although traditionally considered two discrete systems (sympathetic and parasympathetic), the enteric nervous system is now considered a third component of the autonomic nervous system. This chapter reviews the background of the neuroanatomical distribution of the autonomic nervous system in order to facilitate understanding the basics of autonomic function.
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Affiliation(s)
- Christopher H Gibbons
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
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Abstract
Horner syndrome results from an interruption of the oculosympathetic pathway. Patients with Horner syndrome present with a slightly droopy upper lid and a smaller pupil on the affected side; less commonly, there is a deficiency of sweating over the brow or face on the affected side. This condition does not usually cause vision problems or other significant symptoms, but is important as a warning sign that the oculosympathetic pathway has been interrupted, potentially with serious and even life-threatening processes. The oculosympathetic pathway has a long and circuitous course, beginning in the brain and traveling down the spinal cord to exit in the chest, then up the neck and into the orbit. Therefore, this syndrome with unimpressive clinical findings and insignificant symptoms may be a sign of serious pathology in the head, chest, or neck. This clinical review discusses how to identify the signs, confirm the diagnosis, and evaluate the many causes of Horner syndrome.
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Affiliation(s)
- Timothy J. Martin
- Department of Ophthalmology, Wake Forest University School of Medicine, Wiston-Salem, North Carolina 27157, United States
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Agarwala MK, George L, Parmar H, Mathew V. Ross Syndrome: A Case Report and Review of Cases from India. Indian J Dermatol 2016; 61:348. [PMID: 27293279 PMCID: PMC4885212 DOI: 10.4103/0019-5154.182472] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Ross syndrome is a rare dysautonomia characterized by a clinical complex of segmental anhidrosis or hypohidrosis, areflexia, and tonic pupils. A very few cases (≃50) have been reported in literature since its original description in 1958. Here, we report the case of a middle-aged homemaker from Odisha, India, who presented with complaints of segmental hypohidrosis for the past 7 years.
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Affiliation(s)
- Manoj Kumar Agarwala
- Department of Dermatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Leni George
- Department of Dermatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Harshad Parmar
- Department of Pathology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vivek Mathew
- Department of Neurology, Christian Medical College, Vellore, Tamil Nadu, India
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Cheshire WP. Thermoregulatory disorders and illness related to heat and cold stress. Auton Neurosci 2016; 196:91-104. [DOI: 10.1016/j.autneu.2016.01.001] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 12/17/2015] [Accepted: 01/05/2016] [Indexed: 01/22/2023]
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Vasudevan B, Sawhney M, Vishal S. Ross syndrome with ana positivity: a clue to possible autoimmune origin and treatment with intravenous immunoglobulin. Indian J Dermatol 2011; 55:274-6. [PMID: 21063524 PMCID: PMC2965918 DOI: 10.4103/0019-5154.70694] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
A 28-year-old serving soldier presented with patchy areas of absence of sweating and blurring of vision. On examination he was found to have segmental anhidrosis, right sided tonic pupil and absent ankle jerks. Investigations revealed ANA positivity with no other abnormalities. He was treated with Intravenous immunoglobulin. This case of Ross syndrome is reported for its rarity as well as a clue to its probable autoimmune origin and treatment option with intravenous immunoglobulins.
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Affiliation(s)
- Biju Vasudevan
- Department of Dermatology and Venereology, Base Hospital, Delhi Cantt, India
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Abstract
We report a 40-year-old woman who developed Ross syndrome (impairment of sweating and thermoregulation, tonic pupils, and hyporeflexia) associated with cytomegalovirus (CMV) infection. Her serum CMV IgM and IgG antibody titer levels were elevated. Along with clinical improvement, a gradual decrease of her elevated CMV IgM antibody titer level was seen with a continued increase in her CMV IgG antibody titer level. The CMV IgM antibody titer was also positive in the cerebrospinal fluid.
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Affiliation(s)
- Yuriko Nagane
- Department of Neurology, Hanamaki General Hospital, Kajoh-chou 4-28, Hanamaki, Japan.
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Chemmanam T, Pandian JD, Kadyan RS, Bhatti SM. Anhidrosis: A clue to an underlying autonomic disorder. J Clin Neurosci 2007; 14:94-6. [PMID: 17070054 DOI: 10.1016/j.jocn.2005.11.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2005] [Accepted: 11/24/2005] [Indexed: 11/16/2022]
Abstract
We describe a patient with Ross syndrome who had the classic triad of segmental anhidrosis, tonic pupils and hyporeflexia. Dilute pilocarpine (0.1%) instillation in both eyes revealed parasympathetic denervation hypersensitivity. There was evidence of cardiac dysautonomia in the form of a decrease in heart rate variability with deep breathing and an abnormal Valsalva response. A thermoregulatory sweat test showed the presence of sweating in the right cheek, neck and upper one-third of the left arm and shoulder only. Sympathetic skin responses were absent in the affected segments of the upper limb. Ross syndrome is a degenerative disorder that progressively involves different fibre populations, starting with autonomic fibres and then involving the unmyelinated and myelinated sensory fibres. A careful clinical examination and simple bedside autonomic tests can confirm the diagnosis.
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Affiliation(s)
- Thomas Chemmanam
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
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Piqué E, Hernández-Ramos F, Santana Z, Pérez-Cejudo JA. Anhidrosis segmentaria asociada a pupila de Adie: un caso de síndrome de Ross incompleto. ACTAS DERMO-SIFILIOGRAFICAS 2005; 96:455-8. [PMID: 16476274 DOI: 10.1016/s0001-7310(05)73111-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
We present the case of a 43-year-old woman who presented with a localized area of anhidrosis on the upper left trunk and ipsilateral upper limb. It was associated with Adie's tonic pupil and an area of compensatory hyperhidrosis on the contralateral side. After 9 years of follow up, the alterations have remained stable. These alterations of the autonomous nervous system correspond to an incompletely expressed Ross syndrome.
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Affiliation(s)
- Enric Piqué
- Sección de Dermatología, Hospital General de Lanzarote, Las Palmas, Spain.
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Serra Mitjans M, Callejas Pérez M, Valls Solé J, Grimalt Santacana R, Rubio Garay M, Iglesias Sentís M. Tratamiento quirúrgico de la hiperhidrosis compensadora en el síndrome de Adie. Arch Bronconeumol 2004. [DOI: 10.1016/s0300-2896(04)75480-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Thami GP, Kaur S, Kanwar AJ. Acquired idiopathic generalized anhidrosis: a rare cause of heat intolerance. Clin Exp Dermatol 2003; 28:262-4. [PMID: 12780708 DOI: 10.1046/j.1365-2230.2003.01208.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A reduced level or complete cessation of sweating can be caused by a variety of factors affecting sweat glands directly or indirectly through alterations in their nerve supply. The most common presentation is the syndrome of heat intolerance with or without features of dysautonomia. An acquired idiopathic form of generalized anhidrosis is characterized by loss of sweating in the absence of any neurological features or destruction of sweat glands. Cholinergic urticaria has been associated with some cases of this acquired idiopathic form of generalized anhidrosis. A case of generalized absence of sweating without a neurological deficit is described, and the implications of heat intolerance are discussed.
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Affiliation(s)
- G P Thami
- Department of Dermatology and Venereology, Government Medical College Hospital, Chandigarh, India.
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Perretti A, Nolano M, De Joanna G, Tugnoli V, Iannetti G, Provitera V, Cruccu G, Santoro L. Is Ross syndrome a dysautonomic disorder only? An electrophysiologic and histologic study. Clin Neurophysiol 2003; 114:7-16. [PMID: 12495758 DOI: 10.1016/s1388-2457(02)00323-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To define the involvement of peripheral nerve fibers in Ross syndrome. METHODS Mechanical pain perception, tactile and thermal thresholds on hand, foot dorsum, thigh, median nerve orthodromic sensory conduction velocity (SCV) and motor conduction velocity (MCV), sural nerve antidromic SCV, peroneal nerve MCV, H-reflex, F-wave, median, tibial nerve somatosensory evoked potentials (SSEPs), perioral, hand CO(2) laser late (LEPs) and ultralate evoked potentials, sympathetic skin response (SSRs), cardiovascular, Minor sweat, silastic imprint, histamine, photopletysmographic and pupil pilocarpine tests, cutaneous innervation immunohistochemical techniques were studied in 3 patients with Ross syndrome. RESULTS Quantitative sensory testing showed altered results in patients 1 and 2, and patient 3 had a slight impairment of mechanical pain perception. Nerve conduction, except for a median nerve distal reduction of sensory conduction in patient 1, F-wave and SSEP findings were normal; H-reflex was absent at rest in all patients. Hand LEPs were absent in patient 2, ultralate potentials were absent in patients 1 and 2. Skin biopsy showed a disease duration related reduction of unmyelinated and myelinated sensory fibers and a lack of unmyelinated autonomic fibers in all patients. CONCLUSIONS Our data suggest that Ross syndrome is a degenerative disorder involving progressive sudomotor fibers, and then epidermal sensory unmyelinated and myelinated fibers.
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Affiliation(s)
- A Perretti
- Department of Neurological Sciences, University of Naples 'Federico II', Via Sergio Pansini 5, Naples, Italy
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Arjona A, Espino R. [Chronic reflex cough in Ross's syndrome]. Med Clin (Barc) 2000; 115:479. [PMID: 11093867 DOI: 10.1016/s0025-7753(00)71599-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Chudnow RS, Wolfe GI, Sparagana SP, Delgado MR, Batchelor L, Roach ES. Abnormal sudomotor function in the hypomelanotic macules of tuberous sclerosis complex. J Child Neurol 2000; 15:529-32. [PMID: 10961791 DOI: 10.1177/088307380001500806] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
To investigate the integrity of sympathetic innervation in the hypomelanotic macules of tuberous sclerosis complex, we studied sudomotor function in nine patients with tuberous sclerosis complex. Postganglionic sudomotor function was assessed using the Silastic imprint test in nine patients with tuberous sclerosis complex who have at least one hypomelanotic macule greater than 2 cm in diameter. Sweating was induced by iontophoresis with 0.5% pilocarpine nitrate and sweat droplets were counted under a microscope using a 1 x 1 cm grid. Silastic imprint testing of an analogous skin area contralateral to the hypomelanotic macule was measured as a control. Sweat volume quantitation using sweat collectors was performed in five of the subjects. The sweat volume collected from the hypomelanotic macule was reduced compared to the control skin in four of the five subjects. Sweat droplet counts from the hypomelanotic macule were significantly reduced in only one of nine subjects. These data suggest that, although there is no difference in the number of functioning sweat glands in most hypomelanotic macules, the sweat glands produce less sweat (ie, decreased sweat volume) than in normal skin. We hypothesize that focal abnormalities of sympathetic innervation might be responsible for the hypomelanotic macules of tuberous sclerosis complex.
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Affiliation(s)
- R S Chudnow
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas 75235, USA
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Bergmann I, Dauphin M, Naumann M, Flachenecker P, Müllges W, Koltzenburg M, Sommer C. Selective degeneration of sudomotor fibers in Ross syndrome and successful treatment of compensatory hyperhidrosis with botulinum toxin. Muscle Nerve 1998; 21:1790-3. [PMID: 9843086 DOI: 10.1002/(sici)1097-4598(199812)21:12<1790::aid-mus26>3.0.co;2-i] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We report a 5-year follow-up of a patient with Ross syndrome. A biopsy of the anhidrotic skin immunostained with protein gene product 9.5 visualized by confocal microscopy revealed selective loss of sudomotor fibers, whereas epidermal innervation remained intact, providing the first morphologic evidence of selective loss of sudomotor fibers in this syndrome. Among the different treatment strategies employed for the patient's disabling segmental hyperhidrosis, intracutaneous injection of botulinum toxin A was the most helpful.
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Affiliation(s)
- I Bergmann
- Neurologische Universitätsklinik, Würzburg, Germany
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