Bilateral tonic pupils secondary to Ross syndrome: a case report

A guide to identify cervical autonomic dysfunctions (and associated conditions) in patients with musculoskeletal disorders in physical therapy practice

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.

Neuro-Ophthalmology at the Bedside: A Clinical Guide

Neuro-ophthalmological signs and symptoms are common in the emergency department but are a frequent source of diagnostic uncertainties. However, neuro-ophthalmological signs often allow a precise neuro-topographical localization of the clinical problem. A practical concept is presented how to perform a neuro-ophthalmological examination at the bedside and to interpret key findings under the aspect of emergency medicine with limited resources.

An interesting case of simultaneous bilateral Adie's tonic pupil

A tonic pupil is usually caused due to parasympathetic denervation of the iris sphincter muscles. It's usually seen in females and in 80 % cases it's unilateral, and 4% of these cases progress to bilateral involvement. Adie's tonic pupil has been reported in literature to have multiple syndromic associations. Simultaneous bilateral occurrence of Adie's tonic pupil in an asymptomatic healthy adult male is sparsely reported in literature. The diagnostic dilemma in the setting of a busy clinical practice is henceforth discussed.

Is Ross Syndrome an Autoimmune Entity? A Case Series of 11 Patients

Background: Ross syndrome is diagnosed by the presence of segmental anhidrosis, areflexia, and tonic pupils. Fewer than 60 cases have been described in literature so far. There have been reports of presence of antibodies in such patients, suggesting an autoimmune pathogenesis. Methods: We describe the clinical profile in this case series of 11 patients with Ross syndrome and discuss the current status of autoimmunity in its pathogenesis and the management. Results: Of the 11 patients with Ross syndrome there was an almost equal sex distribution (male:female ratio was 1.17:1) and the mean age of onset of symptoms was 26 years. Patients took an average of 6 years to present to a tertiary center. Sixty-three percent of the patients presented with complaints of excessive sweating, whereas only 27% had complaints of decreased sweating over a particular area of the body. Only 45% of the patients had the complete triad of Ross syndrome, which included segmental anhidrosis, tonic pupil, and absent reflexes. Eighty-nine percent of the patients had documented absent sympathetic skin response on electromyography. The various markers of autoimmunity were negative in all patients who were investigated for the same in this series. Ninety percent of the patients were managed conservatively. Conclusions: These findings suggest that, in Ross syndrome, generalized injury to ganglion cells or their projections are not purely autoimmune-mediated.