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release of histamine into the skin as the result of a scratch It can be elicited in sensitive individuals by scratching the skin (dermatographia) The wheal and the deeply colored red areola are caused by the direct action of histamine on blood vessels, while the are depends upon the integrity of the axon re ex, in which antidromic stimulation of small sensory C bers results in the release by the same bers of vasoactive substances such as histamine In familial dysautonomia, the are response to histamine and to scratch is absent It may also be absent in peripheral neuropathies that involve sympathetic nerves (eg, diabetes, alcoholic-nutritional disease, Guillain-Barre disease, amyloidosis, porphyria, etc) The quanti tative sudomotor response to topical acetylcholine, described above, is preferred for its sensitivity and accuracy but requires special equipment Pressor Infusion and Other Direct Cardiovascular Tests The infusion of NE causes a rise in blood pressure, which is usually more pronounced for a given infusion rate in dysautonomic states than it is with normal subjects In many instances, eg, the GuillainBarre syndrome, the excessive rise in blood pressure is thought to be more a result of inadequate muting of the hypertension by baroreceptors than it is a re ection of true denervation hypersensitivity, ie, it re ects dysfunction of the afferent limb of the re ex arc In patients with familial dysautonomia, the infusion of NE also produces erythematous blotching of the skin, like that which may occur under emotional stress, probably representing an exaggerated response to endogenous NE The infusion of angiotensin II into patients with idiopathic orthostatic hypotension also causes an exaggerated blood pressure response A similar response to methacholine and NE has been interpreted as a denervation hypersensitivity to neurotransmitter or related substances A different mechanism must be invoked for the blood pressure response induced by angiotensin; perhaps it is due to defective baroreceptor function The integrity of autonomic innervation of the heart can be evaluated by the intramuscular injection of atropine, ephedrine, or neostigmine while the heart rate is monitored Normally, the intramuscular injection of 08 mg of atropine causes a parasympathetic block and a withdrawal of vagal tone No such change occurs in cases of parasympathetic (vagal) denervation of the heart, the most common such conditions being diabetes and the Guillain-Barre syndrome and the most dramatic being the brain death state, in which there is no longer any tonic vagal activity to be ablated by atropine Microchemical methods are available for the measurement of NE and dopamine -hydroxylase in the serum Normally, when a person changes from a recumbent to a standing position, the serum NE level rises two- or threefold In patients with central and peripheral autonomic failure, there is little or no elevation on standing or with exercise The dopamine -hydroxylase enzyme is de cient in patients with a rare form of sympathetic dysautonomia In summary, the noninvasive tests listed in Table 26-1 and described above are quite adequate for the clinical testing of autonomic function Low has emphasized that the most informative tests are those that are quantitative and have been standardized and validated in patients with both mild and severe autonomic disturbances At the bedside, the most convenient ones are measurement of orthostatic pulse and blood pressure changes, blood pressure response to the Valsalva maneuver, estimation of pulse changes with deep breathing, pupillary responses to light and dark, and a rough estimate of sweating of the palms and soles The results of.

CLINICAL DISORDERS OF THE AUTONOMIC NERVOUS SYSTEM Acute Autonomic Paralysis (Dysautonomic Polyneuropathy; Pure Pandysautonomia)

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Since this condition was rst reported by Young and colleagues in 1975, many more cases in both adults and children have been placed on record Over a period of a week or a few weeks, the patient develops some combination of anhidrosis, orthostatic hypotension, paralysis of pupillary re exes, loss of lacrimation and salivation, impotence, impaired bladder and bowel function (urinary retention, postprandial bloating, and ileus or constipation), and loss of certain pilomotor and vasomotor responses in the skin ( ushing and heat intolerance) Somatosensory and re ex function are usually spared Severe fatigue is a prominent complaint in most patients, and abdominal pain and vomiting in others A few develop sleep apnea or the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), leading to hyponatremia The cerebrospinal uid (CSF) protein is normal or slightly increased Clinical and laboratory ndings indicate that both the sympathetic and parasympathetic parts of the autonomic nervous system are affected, mainly at the postganglionic level Somatosensory and motor nerve bers appear to be spared or are affected to only a slight extent, although many patients complain of paresthesias, and tendon re exes are frequently lost In one of the patients described by Low and colleagues, there was physiologic and morphologic (sural biopsy) evidence of loss of small myelinated and unmyelinated somatic bers and foci of epineurial mononuclear cells; in other cases, sural nerve ber counts have been normal; and in an autopsied case, in which there had also been sensory loss, there was lymphocytic in ltration in sensory and autonomic nerves (Fagius et al) The original patient described by Young and colleagues and most of the other patients reported with pure dysautonomia are said to have recovered completely or almost so within several months, but some of our patients have been left with disordered gastrointestinal and sexual functions In addition to this idiopathic form of autonomic paralysis, some cases are postinfectious, and there is a similar but rare paraneoplastic form (page 586) Antibodies against ganglionic acetylcholine receptors have been found in half of idiopathic cases and one-quarter of paraneoplastic cases (Vernino et al) Some of the children with this disease and a few adults have had a predominantly cholinergic dysautonomia with pain and dysesthesias (Kirby et al) There is little or no postural hypotension, and the course has been more chronic than that in the complete dysautonomia described above In view of the occurrence of identical autonomic disturbances in the Guillain-Barre syndrome and the high incidence of minor degrees of weakness, re ex loss, CSF protein elevation, and especially paresthesias in dysautonomic polyneuropathy, it is likely that the last of these disorders is also an immune polyneuropathy affecting the autonomic bers within peripheral nerves, in many ways comparable to the Guillain-Barre syndrome The aforemen tioned autopsy ndings reported by Fagius and coworkers support such a relationship In animals, autonomic paralysis has been produced by injection of extracts of sympathetic ganglia and Freund s.

adjuvant (Appenzeller et al), similar to the experimental immune neuritis that is considered as an animal model of the Guillain-Barre syndrome An acquired form of orthostatic intolerance, referred to as sympathotonic orthostatic hypotension (Polinsky et al), may represent another variant or partial form of autonomic paralysis In this syndrome, unlike the common forms of orthostatic hypotension (see below), the fall in blood pressure is accompanied by tachycardia Hoeldtke and colleagues, who described four such patients, found that the vasomotor re exes and NE production were normal; these investigators were inclined to attribute the disorder to a process affecting lower thoracic and lumbar sympathetic neurons Its relationship to the similarly indistinct entity of postural orthostatic tachycardia syndrome and to the orthostatic intolerance associated with the chronic fatigue syndrome is uncertain, but asthenia is a feature common to all of them Indeed, similar syndromes in the past have been called neurocirculatory asthenia ( soldiers heart, Da Costa syndrome; see Chap 24) We are inclined to view those so-called orthostatic intolerance syndromes as part of the asthenia-anxiety disorders The autonomic changes may represent sympathetic overactivity in susceptible individuals Lambert-Eaton Myasthenic Syndrome One of the characteristic features of the fully developed Lambert-Eaton myasthenic syndrome, which is discussed more fully on page 1259, is a dysautonomia, characterized by dryness of the mouth, impotence, dif culty in starting the urinary stream, and constipation Presumably, circulating antibodies interfere with the release of acetylcholine (Ach) at both muscarinic and nicotinic sites

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Primary Autonomic Failure (PAF), Idiopathic Orthostatic Hypotension (IOH)

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