Harlequin Syndrome: Still Only Half Understood

Harlequin sign due to an upper thoracic paravertebral lesion. A systematic review of the literature

INTRODUCTION

Harlequin syndrome (HS) is an uncommon condition affecting the sympathetic nervous system, characterized by asymmetrical flushing and sweating impairment, which can affect the face or half of the body. When the dysfunction results from external factors like damage or compression, it's referred to as Harlequin Sign. Our objective was to document an exceedingly rare presentation of Harlequin Sign caused by a T3-T4 paravertebral mass and conduct the first systematic literature review on this subject.

METHODS

We conducted a systematic review of English-language studies using PubMed, Scopus, and Embase databases. We excluded abstracts, posters, congenital and idiopathic Harlequin Syndrome cases, as well as iatrogenic and secondary Harlequin Sign cases related to pathologies other than upper thoracic lesions.

RESULTS

We employed the PRISMA protocol and reviewed 1,538 papers, identifying 8 single case reports describing the Harlequin sign resulting from upper thoracic paravertebral lesions. The mean age of the patients was 41.25 years, with 6 (75 %) being female. The average time from onset to presentation was 8 months, and all patients (100 %) exhibited hemifacial flushing, while 4 (50 %) also had hemifacial anhidrosis. Stress or exercise exacerbated these symptoms in 50 % of cases. Additionally, 3 patients (37.5 %) presented with associated Horner Syndrome. The most commonly used diagnostic tool was a CT scan (50 %), revealing an average tumor diameter of 3.95 cm, with 50 % of cases located at T2-T3. Diagnosis indicated 57 % of cases as schwannomas and 29 % as lung adenocarcinoma (Superior Sulcus). Unfortunately, surgical treatment resolved symptoms in only 25 % of patients.

CONCLUSIONS

Hemifacial or hemibody autonomic symptoms should raise concern for paraspinal lesions in the thoracic spine. In addition to the first comprehensive review on this topic, we present a rare case of a T3/4 paraspinal schwannoma causing Harlequin Syndrome successfully managed with neurosurgical intervention.

Two Cases of Tonic Pupil: Ross and Ross Syndrome Plus

Ross syndrome is a rare disorder of the peripheral autonomic nervous system characterized by a triad of tonic pupils with light-near dissociation, segmental anhidrosis, and areflexia. Though having a benign course, the disease can cause significant social embarrassment. Both our cases presented with complaints of segmental facial hyperhidrosis. The first case with a one-year history had findings of segmental anhidrosis up to T4 thoracic level, left tonic pupil, and absent right ankle reflex. While the second case with a history of five years had bilateral tonic pupil, absent lower limb reflexes, anhidrosis of left face, neck, and upper trunk up to T4 level, apart from having associated Horner’s syndrome. Minor’s (starch-iodine) test and dilute pilocarpine test were helpful for diagnosis in both cases, indicating areas of anhidrosis and pupillary cholinergic denervation hypersensitivity respectively. Both cases were provided counseling and managed conservatively.

Harlequin syndrome in a pediatric population: a case series

Harlequin syndrome is a rare condition, presenting with unilateral facial flushing and hyperhidrosis in response to physical exercise, heat or emotional stressors and has scarcely been reported in pediatric patients. It is caused by a dysfunction of vasomotor and sudomotor sympathetic fiber activity inhibiting the ability to flush on the affected side, causing the neurologically intact side to appear red. We present three pediatric cases of this uncommon syndrome, each of them of different origin and displaying distinct associated (neurological) symptoms, and review medical literature. Insight into the anatomical structure of the thoracocervical and facial sympathetic nervous system is pivotal as it dictates symptomatology. About half of Harlequin syndrome cases are complicated with ocular symptoms and a minority may be part of more extensive partial dysautonomias affecting facial sudomotor, vasomotor and pupillary responses, such as Holmes-Adie syndrome and Ross syndrome. Etiology is generally idiopathic, however, cases secondary to surgery, trauma or infection have been described. Considering its predominantly self-limiting nature, treatment is usually unnecessary and should be restricted to incapacitating cases.

Autonomic History, Examination, and Laboratory Evaluation

PURPOSE OF REVIEW

Autonomic disorders offer a fascinating view of the complexity of the nervous system. Their impact on human health ranges from benign to severe. Deciphering autonomic symptoms and signs draws on the cognitive skills and personal interest in the plight of patients that first attracted many physicians to the field of neurology. This article provides tools to sharpen those skills.

RECENT FINDINGS

Autonomic neuroscience and accumulated clinical knowledge have led to the categorization of autonomic disorders into specific syndromes that can be identified on the basis of clinical phenotypes and physiologic responses to standardized stimuli in the autonomic laboratory. A key development has been the ability to distinguish neurogenic orthostatic hypotension from other causes of hypotension. Quantification of sudomotor responses has proven valuable in the diagnosis of thermoregulatory disorders and small fiber neuropathies such as those related to diabetes mellitus. Increasing attention has focused on autonomic failure as a defining feature of neurodegenerative α-synucleinopathies, especially multiple system atrophy. As awareness of autonomic disorders has increased, the once obscure term dysautonomia has entered into common parlance.

SUMMARY

With appropriate knowledge and experience, neurologists can diagnose autonomic dysfunction accurately and with confidence. The opportunity to play an important role in caring for patients with autonomic disorders is worth the effort.

Do you know this syndrome? Harlequin syndrome

Harlequin syndrome is a rare condition in which one half of the face fails to flush and sweat due to damage of the sympathetic fibers on the ipsilateral side. The majority of cases are idiopathic, but may be iatrogenic or caused by space-occupying lesions or brainstem infarction. We report a case of idiopathic harlequin syndrome in a 34-year-old man with a 5-month history of unilateral facial flushing and sweating after exercise. Despite the rarity of this syndrome, dermatologists should be aware of this condition in order to diagnose properly and provide multidisciplinary assistance.

A pediatric case of idiopathic Harlequin syndrome

Harlequin syndrome, which is a rare disorder caused by dysfunction of the autonomic system, manifests as asymmetric facial flushing and sweating in response to heat, exercise, or emotional factors. The syndrome may be primary (idiopathic) with a benign course, or can occur secondary to structural abnormalities or iatrogenic factors. The precise mechanism underlying idiopathic harlequin syndrome remains unclear. Here, we describe a case of a 6-year-old boy who reported left hemifacial flushing and sweating after exercise. He had an unremarkable birth history and no significant medical history. Complete ophthalmological and neurological examinations were performed, and no other abnormalities were identified. Magnetic resonance imaging was performed to exclude lesions of the cerebrum and cervicothoracic spinal cord, and no abnormalities were noted. His final diagnosis was classic idiopathic harlequin syndrome. Herein, we report the first pediatric case of idiopathic harlequin syndrome in Korea.

Congenital Harlequin syndrome as an isolated phenomenon: A case report and review of the literature

Harlequin syndrome (HS) is a rare autonomic disorder due to a hemifacial cutaneous sympathetic denervation. It is characterized by unilateral diminished sweating and flushing of the face even though after heat or prolonged exercise. It is typically acquired. Congenital cases only represent a 6% of all individuals with HS. All congenital HS cases reported so far showed a concomitant Horner syndrome, probably due to a stellate ganglion involvement. HS represents an uncommon autonomic disorder due to a hemifacial cutaneous sympathetic denervation. It is clinically characterized by a dramatic alteration in facial appearance: ipsilateral denervated pale and dry half from the other intact red and moist half.

CONCLUSION

We present, to the best of our knowledge, the first case of a patient with a congenital HS as an isolated phenomenon.

Harlequin syndrome as a complication of epidural anesthesia

Harlequin syndrome is a rare neurological condition that results in unilateral facial flushing and sweating. Although the syndrome is generally a benign condition with complete resolution if appropriate treatment is initiated, unilateral facial flushing can be a sign of several serious conditions and should be thoroughly investigated. Sudden onset of facial flushing related to harlequin syndrome developed in a patient who had bilateral lung transplant with postoperative epidural anesthesia for pain control. Differential diagnosis includes neurovascular disease (acute stroke), malignant neoplasm of brain or lung, Horner syndrome, idiopathic hyperhidrosis, and Frey syndrome. Harlequin syndrome is often easily treated by discontinuing the anesthetic or adjusting placement of the epidural catheter.

Harlequin Color Change: Neonatal Case Series and Brief Literature Review

First clinical report of Harlequin color change (HCC) phenomenon came in 1952 from Neligan and Strang. Since then, HCC has been described in a fairly broad number of clinical reports involving neonates, infants, children, and adult patients. We here present a small case series of HCC occurring in neonates, pointing out three of the different possible presentations (hemifacial, patchy scattered across the whole body, and hemiscrotal) of this phenomenon. A brief discussion and literature review encompassing epidemiology, clinical features, physiopathology, associated conditions, and differential diagnoses of HCC is then presented. In most cases, HCC represents a benign, idiopathic, and rapidly autoresolutive phenomenon, with no need for treatment. Some drugs (especially anesthetics and prostaglandin E) are thought to enhance HCC expression through their influence on the capillary tone in the peripheral vascular bed; this effect is anyway promptly reversible with drug withdrawal. Only in rare circumstances, HCC may act as a clue for serious central nervous system disorders (e.g., meningitis; hypothalamic, brain stem, or sympathetic nervous system lesions); anyway, in these rare occurrences HCC always represents an epiphenomenon of the disease, never acting as the sole sign of the underlying disorder.

Harlequin syndrome in childhood--case report

Harlequin syndrome happens in only one side of the face. In the affected half, the face does not sweat or flush even with simulation. Arms and trunk could also be affected. This condition is induced by heat, exercise and emotional factors. The article reports a case of a nine-year-old female with a 3-year history of unilateral flushing and sweating after exercise; a brief literature review is included. Despite the rarity of this syndrome, dermatologists should recognize this condition and refer these patients to ophthalmological and neurological examination.