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Rasmussen VF, Schmeichel A, Thrysøe M, Nyengaard JR, Christensen AMR, Vestergaard ET, Kristensen K, Terkelsen AJ, Karlsson P, Singer W. Sweat gland nerve fiber density and association with sudomotor function, symptoms, and risk factors in adolescents with type 1 diabetes. Clin Auton Res 2023; 33:691-703. [PMID: 37682387 PMCID: PMC10751258 DOI: 10.1007/s10286-023-00973-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/08/2023] [Indexed: 09/09/2023]
Abstract
PURPOSE To quantify sweat gland nerve fiber density in adolescents with diabetes. Additionally, to investigate associations between sudomotor innervation, sweat responses, and possible risk factors for sudomotor neuropathy. METHODS Cross-sectional study where 60 adolescents with type 1 diabetes (duration > 5 years) and 23 control subjects were included. Clinical data, quantitative sudomotor axon reflex test, and skin biopsies were obtained. Skin tissue was immunostained and imaged by confocal microscopy. Quantification of the sweat gland volume and three-dimensional reconstruction of the nerve fibers was performed using a design-unbiased technique. RESULTS Adolescents with diabetes had a significant reduction of maximum and mean values of nerve fiber length and nerve fiber density in sweat glands compared to controls (p values < 0.05). No association between nerve fiber density and sweat responses was found (p = 0.21). In cases with reduced sweat gland nerve fiber length, nerve fiber density, and volume, the sweat response was reduced or absent. Height, systolic blood pressure, time in hypoglycemia, and total daily and basal/total insulin dose were positively correlated to sweat response, while low-density lipoprotein, and HbA1c were negatively correlated with sweat response (p values < 0.05). Other microvascular complications and high cholesterol levels increased the relative risk for reduced sweat gland nerve fiber density. CONCLUSION Our findings of reduced sweat gland innervation in a selected group of adolescents add new knowledge about the structural changes that occur in autonomic nerves due to diabetes. Evaluating both the sweat gland innervation and sweat gland volume was important for understanding the association with sweat responses. Further research is needed to understand its clinical relevance.
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Affiliation(s)
- Vinni Faber Rasmussen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
- Department of Pediatrics and Adolescents, Randers Regional Hospital, Randers, Denmark.
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark.
| | - Ann Schmeichel
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Mathilde Thrysøe
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Randel Nyengaard
- Core Center for Molecular Morphology, Section for Stereology and Microscopy, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Ann-Margrethe Rønholt Christensen
- Steno Diabetes Center North Denmark, Aalborg, Denmark
- Department of Pediatrics and Adolescents, Aalborg University Hospital, Aalborg, Denmark
| | - Esben Thyssen Vestergaard
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
- Department of Pediatrics and Adolescents, Aarhus University Hospital, Aarhus, Denmark
| | - Kurt Kristensen
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
- Department of Pediatrics and Adolescents, Aarhus University Hospital, Aarhus, Denmark
| | - Astrid Juhl Terkelsen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Páll Karlsson
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
- Core Center for Molecular Morphology, Section for Stereology and Microscopy, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Small-Fiber-Neuropathien. DGNEUROLOGIE 2022; 5. [PMCID: PMC9559077 DOI: 10.1007/s42451-022-00488-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Die Small-Fiber-Neuropathie (SFN) ist eine Erkrankung des peripheren Nervensystems aufgrund einer isolierten oder vorwiegenden Schädigung dünn myelinisierter Aδ-Fasern und/oder unmyelinisierter C‑Fasern. Für die sichere Diagnose einer SFN ist neben der klinischen Symptomatik mit Schmerzen und Sensibilitätsstörungen, typischerweise mit distal betonter Ausbreitung, der apparative Nachweis einer Rarefizierung oder einer Funktionsstörung der dünn myelinisierten Aδ-Fasern und/oder der unmyelinisierten C‑Fasern gefordert. Im vorliegenden Beitrag wird eine Übersicht über die diagnostischen Verfahren zum Nachweis einer SFN sowie über mögliche Ursachen und Behandlungsoptionen gegeben.
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Minota K, Schmeichel AM, Gehrking JA, Mandrekar JN, Low PA, Singer W. Refined Quantitation of Sweat Gland Innervation. J Neuropathol Exp Neurol 2019; 78:453-459. [PMID: 30861073 PMCID: PMC6467193 DOI: 10.1093/jnen/nlz015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Skin biopsies have gained increasing popularity as a tool to evaluate disorders affecting small nerve fibers. While reports on sweat gland nerve fiber density (SGNFD) to quantitate sudomotor innervation have been promising, methodologies vary significantly. Although conventional stereology is commonly used, no standard technique has been established. We sought to develop an accurate and reproducible technique to quantify SGNFD. Skin punch biopsies from healthy individuals were cut and stained. Images of sweat glands (SGs) were acquired using confocal and widefield microscopes, and optimized using deconvolution. Nerve fibers were reconstructed and nerve fiber length (NFL) was quantified using three-dimensional (3D) automated software. SGNFD was obtained by dividing NFL by SG volume. SGNFD was also assessed using stereology for comparison. Ninety-two SGs from 10 healthy subjects were analyzed by independent observers. Using confocal microscopy, the software reliably traced nerve fibers. In contrast, rendering of nerve fibers was inferior using widefield microscopy. Interobserver reliability was suboptimal using widefield images compared to confocal (ICC = 0.82 vs ICC = 0.98). Correlation between 3D-reconstruction and stereology was poor (ICC = 0.38). The newly developed technique of SGNFD quantitation using 3D reconstruction of SG innervation with confocal microscopy reliably traces nerve fibers, shows outstanding reproducibility, is almost completely unbiased, and superior to conventional stereology methods.
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Affiliation(s)
- Karla Minota
- Department of Neurology, Mayo Clinic, Rochester, Minnesota (KM, AMS, JAG, JNM, PAL, WS)
| | - Ann M Schmeichel
- Department of Neurology, Mayo Clinic, Rochester, Minnesota (KM, AMS, JAG, JNM, PAL, WS)
| | - Jade A Gehrking
- Department of Neurology, Mayo Clinic, Rochester, Minnesota (KM, AMS, JAG, JNM, PAL, WS)
| | - Jay N Mandrekar
- Department of Neurology, Mayo Clinic, Rochester, Minnesota (KM, AMS, JAG, JNM, PAL, WS)
| | - Phillip A Low
- Department of Neurology, Mayo Clinic, Rochester, Minnesota (KM, AMS, JAG, JNM, PAL, WS)
| | - Wolfgang Singer
- Department of Neurology, Mayo Clinic, Rochester, Minnesota (KM, AMS, JAG, JNM, PAL, WS)
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Fealey RD. Thermoregulation in neuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2018; 157:777-787. [PMID: 30459040 DOI: 10.1016/b978-0-444-64074-1.00048-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
Peripheral neuropathy affecting autonomic and small sensory fibers can cause abnormalities of both autonomic and behavioral thermoregulation. Quantitative autonomic and sensory neurophysiologic tests and quantification of the linear density of intraepidermal nerve fibers potentially can stratify those at risk of impaired thermoregulation during cold and heat challenges. New data relating to thermoregulatory sweating impairment in neuropathy are presented in this chapter. Of 516 neuropathy patients analyzed, 345 were found to have thermoregulatory sweat test (TST) abnormalities with a mean percentage of anterior body surface anhidrosis (TST%) of 12% and a significant reduction in total body sweat rate, although the rate of core temperature rise with heating (slope) was not significantly different from that of patients with a normal TST. However a subset of abnormal TST patients having 25% or greater TST% showed a significantly more rapid rise in core temperature (lower slope) than age- and sex-matched neuropathy patients with a normal TST. Etiologies of neuropathy in this more severe group included diabetes, erythromelalgia, immune-mediated autonomic neuropathy, primary systemic amyloidosis, and neuropathy associated with postganglionic-autonomic degenerative disorders.
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Affiliation(s)
- Robert D Fealey
- Department of Neurology, Mayo Clinic, Rochester, MN, United States.
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Autonomic Nervous System Dysregulation in Monozygous Twins With Nephropathic Cystinosis. Kidney Int Rep 2018; 3:1489-1496. [PMID: 30450477 PMCID: PMC6224624 DOI: 10.1016/j.ekir.2018.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Loavenbruck A, Sit N, Provitera V, Kennedy W. High-resolution axon reflex sweat testing for diagnosis of neuropathy. Clin Auton Res 2018; 29:55-62. [DOI: 10.1007/s10286-018-0546-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 07/05/2018] [Indexed: 02/03/2023]
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Loavenbruck AJ, Hodges JS, Provitera V, Nolano M, Wendelshafer-Crabb G, Kennedy WR. A device to measure secretion of individual sweat glands for diagnosis of peripheral neuropathy. J Peripher Nerv Syst 2018; 22:139-148. [PMID: 28429515 DOI: 10.1111/jns.12212] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 03/29/2017] [Accepted: 04/03/2017] [Indexed: 11/28/2022]
Abstract
There is a need for quantitative, precise assessment of small fiber peripheral nerve function. We tested a customized camera device and protocol designed to quantify secretions of individual sweat glands (SGs). Testing was performed on 178 healthy controls and 20 neuropathy subjects. Sweating was stimulated on a 2.25 cm2 skin area by iontophoresis of pilocarpine. The camera imaged sweat from 50 to 400 sweat ducts. We calculated secretion rate of individual SGs, total sweat volume, and number of secreting SGs at four body sites. Neuropathy subjects were tested at the two distal sites to demonstrate the device's capability to detect abnormal sudomotor function. Normal ranges were calculated for each body site. Neuropathy subjects had lower sweat rates per SG, lower total sweat, and lower SG density. The normal values decreased with advancing age, were lower in females, and differed between body sites. There was good agreement with repeat testing. The device provides reliable, precise quantitative measures of sweat secretion from single SGs for characterization of sudomotor nerve function in healthy control subjects and in subjects with known peripheral neuropathy. The test combines the capabilities of existing tests of sudomotor function while providing additional capabilities.
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Affiliation(s)
| | - James S Hodges
- Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | | | - Maria Nolano
- Telese Terme, 'S. Maugeri' Foundation IRCCS, Benevento, Italy
| | | | - William R Kennedy
- Department of Neurology, University of Minnesota, Minneapolis, MN, USA
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Sensory and autonomic function and structure in footpads of a diabetic mouse model. Sci Rep 2017; 7:41401. [PMID: 28128284 PMCID: PMC5269750 DOI: 10.1038/srep41401] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 12/19/2016] [Indexed: 12/12/2022] Open
Abstract
Sensory and autonomic neuropathy affects the majority of type II diabetic patients. Clinically, autonomic evaluation often focuses on sudomotor function yet this is rarely assessed in animal models. We undertook morphological and functional studies to assess large myelinated and small unmyelinated axons in the db/db type II diabetes mouse model. We observed that autonomic innervation of sweat glands in the footpads was significantly reduced in db/db mice compared to control db/+ mice and this deficit was greater compared to reductions in intraepidermal sensory innervation of adjacent epidermis. Additionally, db/db mice formed significantly fewer sweat droplets compared to controls as early as 6 weeks of age, a time when no statistical differences were observed electrophysiologically between db/db and db/+ mice studies of large myelinated sensory and motor nerves. The rate of sweat droplet formation was significantly slower and the sweat droplet size larger and more variable in db/db mice compared to controls. Whereas pilocarpine and glycopyrrolate increased and decreased sweating, respectively, in 6 month-old controls, db/db mice did not respond to pharmacologic manipulations. Our findings indicate autonomic neuropathy is an early and prominent deficit in the db/db model and have implications for the development of therapies for peripheral diabetic neuropathy.
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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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Vinik AI, Nevoret ML, Casellini C. The New Age of Sudomotor Function Testing: A Sensitive and Specific Biomarker for Diagnosis, Estimation of Severity, Monitoring Progression, and Regression in Response to Intervention. Front Endocrinol (Lausanne) 2015; 6:94. [PMID: 26124748 PMCID: PMC4463960 DOI: 10.3389/fendo.2015.00094] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 05/23/2015] [Indexed: 12/27/2022] Open
Abstract
Sudorimetry technology has evolved dramatically, as a rapid, non-invasive, robust, and accurate biomarker for small fibers that can easily be integrated into clinical practice. Though skin biopsy with quantitation of intraepidermal nerve fiber density is still currently recognized as the gold standard, sudorimetry may yield diagnostic information not only on autonomic dysfunction but also enhance the assessment of the small somatosensory nerves, disease detection, progression, and response to therapy. Sudorimetry can be assessed using Sudoscan™, which measures electrochemical skin conductance (ESC) of hands and feet. It is based on different electrochemical principles (reverse iontophoresis and chronoamperometry) to measure sudomotor function than prior technologies, affording it a much more practical and precise performance profile for routine clinical use with potential as a research tool. Small nerve fiber dysfunction has been found to occur early in metabolic syndrome and diabetes and may also be the only neurological manifestation in small fiber neuropathies, beneath the detection limits of traditional nerve function tests. Test results are robust, accomplished within minutes, require little technical training and no calculations, since established norms have been provided for the effects of age, gender, and ethnicity. Sudomotor testing has been greatly under-utilized in the past, restricted to specialized centers capable of handling the technically demanding and expensive technology. Yet, evaluation of autonomic and somatic nerve function has been shown to be one of the best estimates of cardiovascular risk. Evaluation of sweating has the appeal of quantifiable non-invasive determination of the integrity of the peripheral autonomic nervous system, and can now be accomplished rapidly at point of care clinics with the determination of ESC, allowing intervention for morbid complications prior to permanent structural nerve damage. We review here sudomotor function testing technology, the research evidence accumulated supporting the clinical utility of measuring ESC, the medical applications of sudorimetry now available to physicians with this device, and clinical vignettes illustrating its use in the clinical decision-making process.
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Affiliation(s)
- Aaron I. Vinik
- Division of Endocrinology and Metabolism, Department of Medicine, Strelitz Diabetes and Neuroendocrine Center, Eastern Virginia Medical School, Norfolk, VA, USA
| | | | - Carolina Casellini
- Division of Endocrinology and Metabolism, Department of Medicine, Strelitz Diabetes and Neuroendocrine Center, Eastern Virginia Medical School, Norfolk, VA, USA
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Névoret ML, Vinik AI. CIDP variants in diabetes: measuring treatment response with a small nerve fiber test. J Diabetes Complications 2015; 29:313-7. [PMID: 25466645 DOI: 10.1016/j.jdiacomp.2014.10.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 10/27/2014] [Accepted: 10/29/2014] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Chronic inflammatory demyelinating polyneuropathy (CIDP) is eleven times more common among people with diabetes than the general population and is treatable with appropriate immunotherapy. Treatment response is usually measured clinically (symptomatic and functional improvement). We present a case of a patient with type 2 diabetes (T2D) and CIDP whose treatment response was measurable with the Sudoscan sudomotor function test. This test may represent a new objective evaluation of the treatment of CIDP. CASE DESCRIPTION The patient is a 60year old male initially referred to our center in August 2012, at which time he was diagnosed with CIDP based on AAN electrodiagnostic criteria (NCS). Autonomic functions were significant for low heart rate variability response to expiration/inspiration (E/I), Valsalva maneuver and the ratio of the RR interval for the 30th to the 15th beat upon standing (1.08, 1.12, 1.05 respectively), and frequency analysis of the total spectral power, the standard deviation of the normal RR intervals (sdNN) and their root mean squared (rmsSD). Sudoscan electrochemical skin conductances (ESC), measuring small nerve fiber function on the palms and soles, were very low: 23 μS in the feet and 32 μS in the hands. After one cycle of intravenous immunoglobulin (IVIG: 6 doses total, 75g each) the patient had no change in symptoms of burning, numbness, shooting pains, and gait impairment. However, E/I, Valsalva, and 30:15 ratios (1.19, 1.36, 1.39 respectively) were improved, as were NCS. Sudoscan scores for feet and hands were unchanged (23 μS and 32 μS). In March 2013, the patient's autonomic functions worsened (E/I, Valsalva, and 30:15 ratios 1.1, 1.07, 1.12 respectively), but feet and hand ESC started to show improvement (35 μS and 52 μS respectively). Azathioprine was started. Eight days after a second cycle of IVIG in January 2014, the patient reported for the first time less burning, shooting pains and tingling. E/I, Valsalva, and 30:15 ratios remained low (1.03, 1.07, and not analyzable, respectively), while foot and hand ESC scores continued to improve (43 μS and 55 μS respectively). DISCUSSION CIDP diagnosis and treatment response are difficult in the diabetic patient. We found that NCS and autonomic function tests did not correlate well with clinical status while numerical Sudoscan scores matched closely symptomatic changes. ESC have been found to correlate well with peripheral small fiber function and neuropathic symptoms in DPN. The findings in this patient warrant further investigation of the use of Sudoscan to monitor CIDP response to therapy.
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