Reflex sympathetic dystrophy: occurrence of chronic edema and nonimmune bullous skin lesions

Arriving at SKINTED (Surgery of the Knee, Injury to the Infrapatellar Branch of the Saphenous Nerve, Traumatic Eczematous Dermatitis): A Case Report

Surgery of the knee, injury to the infrapatellar branch of the saphenous nerve, traumatic eczematous dermatitis (SKINTED) is a postsurgical localized dermatitis specifically linked to total knee arthroplasty (TKA). It is due to autonomic denervation following surgically inflicted nerve injury. It develops several months to years following a surgical trauma. It is being referred to by various names in the literature. Locoregional immune dysfunction due to lymphatic injury after surgery is the currently accepted theory. It must be distinguished from atopic dermatitis, allergic contact dermatitis/sensitization induced by topical medications or implanted metal hypersensitivity dermatitis, and post-traumatic eczema/dermatitis. We present a case of an elderly female patient in her 50s with dry eczematous lesions over the lateral aspect of the surgical incision over both knees developed three months following bilateral total knee replacement (TKR) done in view of osteoarthritis. The patient responded well to topical corticosteroid and emollient treatment. We have also reviewed the literature to provide an overview of potential concepts of etiopathogenesis described in the literature and to clear up any ambiguity surrounding various labels given to this entity.

Sympathetic dysfunction dermatitis in a revascularised upper extremity after near-total amputation - A case report and review of literature

Commonly reported complications after revascularisation or replantation of extremity are vascular thrombosis leading to complete or partial failure, bony non-union or malunion, joint stiffness and incomplete or abnormal sensory recovery. Sympathetic dysfunction dermatitis is an unreported complication after revascularisation or replantation surgery which results due to denervation of the extremity. We report a case of a young adult who developed eczematous dermatitis over the revascularised upper limb and discuss the role of sympathetic dysfunction in the development of these skin lesions. The patient was successfully treated with a short course of oral and topical steroids. Sympathetic dysfunction dermatitis is a rare form of skin eruptions occurring in the revascularised or replanted part of an extremity due to abnormal sympathetic function in the affected part.

Immunotherapy Prospects for Painful Small-fiber Sensory Neuropathies and Ganglionopathies

The best-known peripheral neuropathies are those affecting the large, myelinated motor and sensory fibers. These have well-established immunological causes and therapies. Far less is known about the somatic and autonomic "small fibers"; the unmyelinated C-fibers, thinly myelinated A-deltas, and postganglionic sympathetics. The small fibers sense pain and itch, innervate internal organs and tissues, and modulate the inflammatory and immune responses. Symptoms of small-fiber neuropathy include chronic pain and itch, sensory impairment, edema, and skin color, temperature, and sweating changes. Small-fiber polyneuropathy (SFPN) also causes cardiovascular, gastrointestinal, and urological symptoms, the neurologic origin of which often remains unrecognized. Routine electrodiagnostic study does not detect SFPN, so skin biopsies immunolabeled to reveal axons are recommended for diagnostic confirmation. Preliminary evidence suggests that dysimmunity causes some cases of small-fiber neuropathy. Several autoimmune diseases, including Sjögren and celiac, are associated with painful small-fiber ganglionopathy and distal axonopathy, and some patients with "idiopathic" SFPN have evidence of organ-specific dysimmunity, including serological markers. Dysimmune SFPN first came into focus in children and teenagers as they lack other risk factors, for example diabetes or toxic exposures. In them, the rudimentary evidence suggests humoral rather than cellular mechanisms and complement consumption. Preliminary evidence supports efficacy of corticosteroids and immunoglobulins in carefully selected children and adult patients. This paper reviews the evidence of immune causality and the limited data regarding immunotherapy for small-fiber-predominant ganglionitis, regional neuropathy (complex regional pain syndrome), and distal SFPN. These demonstrate the need to develop case definitions and outcome metrics to improve diagnosis, enable prospective trials, and dissect the mechanisms of small-fiber neuropathy.

Effect of spinal cord stimulation in Type I complex regional pain syndrome with 2 rare severe cutaneous manifestations

The authors present the case of a 49-year-old female patient with complex regional pain syndrome-Type I (CRPSI) who was suffering from nonhealing wounds and giant bullae, which dramatically improved after spinal cord stimulation (SCS). The scientific literature concerning severe cutaneous manifestations of CRPS-I and their treatment is reviewed. Nonhealing wounds and bullae are rare manifestations of CRPS-I that are extremely difficult to treat. Immediate improvement of both wounds and bullae after SCS, such as in this case, has not been reported previously in literature. Considering the rapidly progressive nature of these severe skin manifestations, immediate treatment, possibly with SCS, is mandatory.

Extensive skin necrosis of the arm in a patient with complex regional pain syndrome

We report a 36-year-old woman with complex regional pain syndrome (CRPS) type 1 presenting with extensive skin necrosis of the left arm. The patient cooled her arm with ice packs to ease severe pain due to CRPS, in spite of repeated cautions against frostbite injury. The regions of skin necrosis corresponded with the sites where she had applied ice packs. We considered that the severe skin necrosis in our case was due to a self-induced frostbite injury.

[Reflex sympathetic dystrophy: description of a case with skin lesions]

Reflex sympathetic dystrophy or algodystrophy is a poorly defined syndrome in which the patient develops pain disproportionate to the cause. It is included among the complex regional pain syndromes. The symptoms are triggered by some type of trauma, at times trivial, and consist of burning pain, edema, changes in skin color, alterations in vascularization, temperature changes, hyperhidrosis and skin disorders, which primarily consist of atrophic changes. Other less frequent cutaneous manifestations have been described in patients with this syndrome. These include papules, blisters, inflammatory lesions and reticulated hyperpigmentation. We discuss the case of a patient with reflex sympathetic dystrophy who presented with superficial ulcers on the affected limb, which mimicked dermatitis artefacta.

Vascular diseases are the most common cutaneous manifestations of reflex sympathetic dystrophy

Reflex sympathetic dystrophy (RSD) is a chronic pain syndrome with prominent cutaneous findings. Atrophy has been considered to be the most common manifestation of the disease. We catalogued the abnormal skin conditions in RSD by means of chart review. Vascular problems were most common, followed by inflammatory diseases, infections, and atrophic diseases. Atrophic disease accounts for a minority of the skin problems seen in RSD. Most cutaneous complaints were related to vascular disease, particularly edema.

Severe complications of reflex sympathetic dystrophy: infection, ulcers, chronic edema, dystonia, and myoclonus

OBJECTIVE

To determine the prevalence, type of complication, predisposing factors, and treatment for severe complications in a population of reflex sympathetic dystrophy (RSD) patients.

DESIGN

Retrospective analysis of the data from RSD patients collected over a 12-year period, to investigate the involvement of predisposing factors in an RSD population without severe complications compared with an RSD population with severe complications.

SETTING

Outpatient clinic of a department of surgery of a university hospital.

PATIENTS

A total of 1,006 patients with the diagnosis of RSD established according to prospectively defined criteria.

MAIN OUTCOME MEASURES

The signs and symptoms of every RSD patient who visited the department were prospectively documented in the medical history; these data were retrospectively analyzed with special regard to RSD with severe complications-infection, ulcers, chronic edema, dystonia, and/or myoclonus-for prevalence, type of complication, and treatment.

RESULTS

Seventy-four RSD patients who were mostly young and female developed severe complications. More than one complication occurred in 91% of the affected extremities. Severe complications developed more frequently in the lower extremity (65%). In patients in whom the acute RSD started with a decreased skin temperature of the affected extremity, severe complications developed significantly more often than in acute RSD patients with a warm skin temperature of the extremity from the onset of the disease (p < .001).

CONCLUSIONS

It is important to recognize "cold" RSD immediately at the onset of the disease because this group of RSD patients has a higher risk of developing a severe complication, mostly followed by a severe disability that is resistant to therapy.

Reflex sympathetic dystrophy with mutilating ulcerations suspicious of a factitial origin

Reflex sympathetic dystrophy (RSD) is a poorly understood posttraumatic pain syndrome associated with dysfunction of the sympathetic nervous system. Pain is often out of proportion to the extent of injury. Progression of the disease may lead to dystrophic and atrophic changes resulting in total disability of an affected limb. Skin findings are highly variable and nonspecific and may rarely include bullae and ulcerations. We describe a mutilating case of RSD with unusual and severely disfiguring ulcerations that necessitated amputation of the right arm. Shortly after the amputation, ulcerations began appearing on the left arm. We suspect a factitial component but have been unable to prove or disprove it. We propose that some ulcerations in patients with RSD may be factitial in origin.

Saphenous vein graft donor site dermatitis in Japan

Four cases of saphenous vein graft donor site dermatitis are reported from Japan for the first time. The patients were four Japanese men aged from 57 to 69. They noted pruritic eruptions along the lower extremity scar after coronary artery bypass graft surgery using the autogenous saphenous vein. The eruptions appeared mainly on and around the lower end of the venectomy scars from 1.5 to 9 months after graft operations performed at three different hospitals. All four patients showed an objective sensory deficit of the saphenous nerve around the saphenous vein incision scar, although none of them complained of saphenous neuralgia subjectively. Histologically, two patients showed mild epidermal acanthosis, spongiosis, intraepidermal blisters, and perivascular infiltration of lymphocytes and a few eosinophils around dermal blood vessels. The eruption responded well to topical corticosteroids in all cases, although it recurred again in two patients. The entity is characterized by a subacute (belatedly appearing, then slowly disappearing) dermatitis and a mild sensory deficit of the saphenous nerve. Apparently, mild impediment of the saphenous nerve due to an ablational procedure of saphenous venectomy can play a role in causing saphenous vein graft donor site dermatitis.

Reflex sympathetic dystrophy with prominent involvement of the nail apparatus

After closed hand trauma, a 17-year-old boy had acute inflammatory changes that resembled bacterial whitlows of the third and fourth right fingers. Clearing of the inflammatory changes was followed by the development of cyanosis, hyperhidrosis, and roentgenographic evidence of patchy osteoporosis in the involved extremity. Findings of a biopsy specimen revealed that the inflammatory lesions in the proximal nail folds were caused by proliferation of capillary vessels embedded in edematous loose connective tissue. This is the first report of cutaneous histopathologic findings in the first stage of reflex sympathetic dystrophy, although similar features have been described in synovial and bone biopsy specimens of patients with reflex sympathetic dystrophy.