1
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Palma JA. Dysautonomia and response to guanfacine in individuals with an SCN9A variant. Clin Auton Res 2024:10.1007/s10286-024-01029-0. [PMID: 38652422 DOI: 10.1007/s10286-024-01029-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 04/25/2024]
Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center and Autonomic Disorders Division, New York University Langone Health and New York University Grossman School of Medicine, 530 First Av, Suite 9Q, New York, NY, 10016, USA.
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2
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Bourkas AN, Geng R, Sibbald M, Sibbald RG. A case of erythromelalgia with gastrointestinal dysautonomia treated with immunoglobulin: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231213137. [PMID: 38022850 PMCID: PMC10658769 DOI: 10.1177/2050313x231213137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/01/2023] [Indexed: 12/01/2023] Open
Abstract
An 18-year-old female with a history of atopic march, hyperhidrosis, and eosinophilic esophagitis was diagnosed with erythromelalgia and gastrointestinal dysautonomia secondary to presumed autoimmune small fiber neuropathy. The patient experienced significant clinical improvements after the initiation of intravenous immunoglobulin therapy, supporting an underlying autoimmune disorder.
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Affiliation(s)
| | - Ryan Geng
- Temerty School of Medicine, University of Toronto, Toronto, ON, Canada
| | - Matthew Sibbald
- Department of Medicine, McMaster Education Research Innovation and Theory (MERIT) Program, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - R Gary Sibbald
- Dalla Lana School of Public Health & Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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3
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Chatterjee S. Coexistence of erythromelalgia and Raynaud's phenomenon. Joint Bone Spine 2023; 90:105561. [PMID: 36933784 DOI: 10.1016/j.jbspin.2023.105561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/18/2023] [Accepted: 03/01/2023] [Indexed: 03/18/2023]
Affiliation(s)
- Soumya Chatterjee
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH 44195, United States.
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4
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Ishida Y, Ouchi H, Kan T, Shinohara H, Nakajima K, Nagaoka Y. [Isolating Venomous Constituents of Paralepistopsis acromelalgaand Simultaneous Analysis of Its Compounds]. Shokuhin Eiseigaku Zasshi 2022; 63:79-84. [PMID: 35650032 DOI: 10.3358/shokueishi.63.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
An isolation method for Acromelic acids A, B and Clitidine, which are venomous constituents of Paralepistopsis acromelalga was developed. Highly purified products were obtained from the mushroom extract using silica gel, ODS, ion-exchange column chromatography and preparative TLC. Using those results, we optimized the LC-MS/MS conditions. Finally we developed a method for simultaneous analysis. In recovery tests, the average recovery was 80.8-112.4%, repeatability was 1.4-3.8RSD%. The limits of quantification of the respective compounds were estimated as 0.25 μg/g. Based on the results, this method can reveal causes of food poisoning by Paralepistopsis acromelalga.
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Affiliation(s)
| | - Hitoshi Ouchi
- School of Pharmaceutical Sciences, University of Shizuoka
| | - Toshiyuki Kan
- School of Pharmaceutical Sciences, University of Shizuoka
| | | | | | - Yuka Nagaoka
- The Yamagata Prefectural Institute of Public Health
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5
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Klein-Weigel P, Ruttloff A, König D, Nielitz J, Steindl J, Sander O, Richter JG. [Functional vascular acrosyndromes]. Inn Med (Heidelb) 2022; 63:591-600. [PMID: 35925129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 06/15/2023]
Abstract
Vascular acrosyndromes are characterized by sparse, uniform clinical manifestations and a variety of possible pathomechanisms. The present article focuses on the functional entities. Raynaud phenomenon is based on cold- or stress-induced vasospasms of acral arteries. It is defined by the color changes of the skin, in the typical case white-blue-red (tricolore). The long fingers are most commonly affected. The etiology is unknown, and the pathophysiology is poorly understood. A distinction is made between primary and a secondary Raynaud phenomenon. The most important underlying diseases include collagenosis, primarily systemic sclerosis, and malignancies; furthermore, medications and drugs may promote vasospasm. Treatment is aimed at preventing or breaking the vasospasm, but has been only partially effective in doing so. Acrocyanosis is a vasospastic dystonic acral disorder that results in permanent reddish-livid discoloration, especially of the hands and feet. Secondary forms occur in collagenosis, malignancies, and myelodysplastic syndromes. The etiology and pathophysiology are virtually unknown. Targeted pharmacological intervention is not possible. Unlike all other vascular acrosyndromes, erythromelalgia is characterized by hyperemia. The primary form is a genetic sodium channelopathy, while secondary forms include malignancies, connective tissue diseases, and myelodysplastic syndromes. The symptoms are often distressing and disabling. Therapy requires a multimodal approach that includes both nonpharmacological and pharmacological strategies. Close interdisciplinary collaboration is essential for the management of this disease.
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Affiliation(s)
- Peter Klein-Weigel
- Klinik für Angiologie, Klinikum Ernst von Bergmann, Charlottenstr. 72, 14467, Potsdam, Deutschland.
| | - Andreas Ruttloff
- Klinik für Angiologie, Klinikum Ernst von Bergmann, Charlottenstr. 72, 14467, Potsdam, Deutschland
| | - Dana König
- Klinik für Angiologie, Klinikum Ernst von Bergmann, Charlottenstr. 72, 14467, Potsdam, Deutschland
| | - Jessica Nielitz
- Klinik für Angiologie, Klinikum Ernst von Bergmann, Charlottenstr. 72, 14467, Potsdam, Deutschland
| | - Julia Steindl
- Klinik für Angiologie, Klinikum Ernst von Bergmann, Charlottenstr. 72, 14467, Potsdam, Deutschland
| | - Oliver Sander
- Poliklinik und Funktionsbereich für Rheumatologie & Hiller-Forschungszentrum für Rheumatologie, Universitätsklinikum Düsseldorf, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - Jutta G Richter
- Poliklinik und Funktionsbereich für Rheumatologie & Hiller-Forschungszentrum für Rheumatologie, Universitätsklinikum Düsseldorf, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
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6
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Yuan JH, Estacion M, Mis MA, Tanaka BS, Schulman BR, Chen L, Liu S, Dib-Hajj FB, Dib-Hajj SD, Waxman SG. KCNQ variants and pain modulation: a missense variant in Kv7.3 contributes to pain resilience. Brain Commun 2021; 3:fcab212. [PMID: 34557669 PMCID: PMC8454204 DOI: 10.1093/braincomms/fcab212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 07/13/2021] [Accepted: 07/29/2021] [Indexed: 12/02/2022] Open
Abstract
There is a pressing need for understanding of factors that confer resilience to pain. Gain-of-function mutations in sodium channel Nav1.7 produce hyperexcitability of dorsal root ganglion neurons underlying inherited erythromelalgia, a human genetic model of neuropathic pain. While most individuals with erythromelalgia experience excruciating pain, occasional outliers report more moderate pain. These differences in pain profiles in blood-related erythromelalgia subjects carrying the same pain-causative Nav1.7 mutation and markedly different pain experience provide a unique opportunity to investigate potential genetic factors that contribute to inter-individual variability in pain. We studied a patient with inherited erythromelalgia and a Nav1.7 mutation (c.4345T>G, p. F1449V) with severe pain as is characteristic of most inherited erythromelalgia patients, and her mother who carries the same Nav1.7 mutation with a milder pain phenotype. Detailed six-week daily pain diaries of pain episodes confirmed their distinct pain profiles. Electrophysiological studies on subject-specific induced pluripotent stem cell-derived sensory neurons from each of these patients showed that the excitability of these cells paralleled their pain phenotype. Whole-exome sequencing identified a missense variant (c.2263C>T, p. D755N) in KCNQ3 (Kv7.3) in the pain resilient mother. Voltage-clamp recordings showed that co-expression of Kv7.2-wild type (WT)/Kv7.3-D755N channels produced larger M-currents than that of Kv7.2-WT/Kv7.3-WT. The difference in excitability of the patient-specific induced pluripotent stem cell-derived sensory neurons was mimicked by modulating M-current levels using the dynamic clamp and a model of the mutant Kv7.2-WT/Kv7.3-D755N channels. These results show that a 'pain-in-a-dish' model can be used to explicate genetic contributors to pain, and confirm that KCNQ variants can confer pain resilience via an effect on peripheral sensory neurons.
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Affiliation(s)
- Jun-Hui Yuan
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Mark Estacion
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Malgorzata A Mis
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Brian S Tanaka
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Betsy R Schulman
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Lubin Chen
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Shujun Liu
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Fadia B Dib-Hajj
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Sulayman D Dib-Hajj
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Stephen G Waxman
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
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Lazareth I, Yannoutsos A. Erythermalgia (erythromelalgia). Redefining the classification of adult erythromelalgia. J Med Vasc 2021; 46:159-162. [PMID: 34238509 DOI: 10.1016/j.jdmv.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Indexed: 06/13/2023]
Affiliation(s)
- I Lazareth
- Vascular Medicine Department, Saint-Joseph Hospital, Paris, France.
| | - A Yannoutsos
- Vascular Medicine Department, Saint-Joseph Hospital, Paris, France
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Portugal F, Araújo A, Silva C, Campos M, Valentim A. Combination gel of 2% amitriptyline and 0.5% ketamine to treat refractory erythromelalgia pain - a case report of pain control success. Rev Esp Anestesiol Reanim (Engl Ed) 2021; 68:293-296. [PMID: 33358428 DOI: 10.1016/j.redar.2020.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/18/2020] [Accepted: 05/21/2020] [Indexed: 06/12/2023]
Abstract
Erythromelalgia (EM) is a rare autosomal dominant neuropathy characterized by the combination of severe burning pain and erythematous warm extremities. Chronic pain control is most often unsuccessful and a completely effective therapy is yet to be identified. Recent studies have reported significant improvements in pain management using a combination of amitriptyline and ketamine in a topical formulation. We describe a 1-year follow-up pain control success case of a male patient with EM, proposed for topical use of a 2% Amitriptyline and 0.5% Ketamine gel.
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Affiliation(s)
- F Portugal
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Chronic Pain Unit, Department of Anaesthesiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - A Araújo
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Chronic Pain Unit, Department of Anaesthesiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - C Silva
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Chronic Pain Unit, Department of Anaesthesiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - M Campos
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Chronic Pain Unit, Department of Anaesthesiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - A Valentim
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Chronic Pain Unit, Department of Anaesthesiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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Portugal F, Araújo A, Silva C, Campos M, Valentim A. Combination gel of 2% amitriptyline and 0.5% ketamine to treat refractory erythromelalgia pain - a case report of pain control success. Rev Esp Anestesiol Reanim (Engl Ed) 2021; 68:293-296. [PMID: 34140126 DOI: 10.1016/j.redare.2020.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/21/2020] [Indexed: 06/12/2023]
Abstract
Erythromelalgia (EM) is a rare autosomal dominant neuropathy characterized by the combination of severe burning pain and erythematous warm extremities. Chronic pain control is most often unsuccessful and a completely effective therapy is yet to be identified. Recent studies have reported significant improvements in pain management using a combination of amitriptyline and ketamine in a topical formulation. We describe a 1-year follow-up pain control success case of a male patient with EM, proposed for topical use of a 2% Amitriptyline and 0.5% Ketamine gel.
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Affiliation(s)
- F Portugal
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Chronic Pain Unit, Department of Anaesthesiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - A Araújo
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Chronic Pain Unit, Department of Anaesthesiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - C Silva
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Chronic Pain Unit, Department of Anaesthesiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - M Campos
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Chronic Pain Unit, Department of Anaesthesiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - A Valentim
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Chronic Pain Unit, Department of Anaesthesiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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10
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Reach P, Lazareth I, Coudore F, Stansal A, Attal R, Michon-Pasturel U, Ghaffari P, Yannoutsos A, Beaussier H, Sacco E, Wang M, Priollet P, Lefaucheur JP, Zuber M. A reappraisal of the presence of small or large fiber neuropathy in patients with erythromelalgia. Neurophysiol Clin 2021; 51:349-55. [PMID: 33888389 DOI: 10.1016/j.neucli.2021.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/31/2021] [Accepted: 03/31/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To assess the contribution of large and small nerve fiber alteration in erythromelalgia (EM). METHODS Thirty-three EM patients were included and underwent clinical evaluation based on EM severity score, DN4, and Utah Early Neuropathy Scale (UENS) score. Neurophysiological evaluation consisted in nerve conduction studies (NCS) for large nerve fibers and specific tests for small nerve fibers: electrochemical skin conductance, cold and warm detection thresholds, and laser evoked potentials. Finally, the evaluation of vascular changes was based on the presence of clinical feature of microvascular disorders and the measurement of the Toe Pressure Index (TPI). RESULTS While 28 patients (85%) had vascular alteration on TPI or clinical features, 23 patients (70%) had small-fiber neuropathy on neurophysiological tests, and only 10 patients (30%) had large fiber neuropathy on NCS. Regarding clinical scores, there was no difference between groups (presence or absence of large- or small-fiber neuropathy or microvascular disorder) except for a higher UENS score in patients with large fiber neuropathy. CONCLUSION Peripheral neuropathy, mostly involving small nerve fibers, is almost as common as microvascular changes in EM, but remains inconstant and not related to a specific neuropathic pattern or higher clinical severity. SIGNIFICANCE The association of neuropathic and vascular factors is not systematic in EM, this syndrome being characterized by different pathophysiological mechanisms leading to a common clinical phenotype.
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Le Cann K, Meents JE, Sudha Bhagavath Eswaran V, Dohrn MF, Bott R, Maier A, Bialer M, Hautvast P, Erickson A, Rolke R, Rothermel M, Körner J, Kurth I, Lampert A. Assessing the impact of pain-linked Nav1.7 variants: An example of two variants with no biophysical effect. Channels (Austin) 2021; 15:208-228. [PMID: 33487118 PMCID: PMC7833769 DOI: 10.1080/19336950.2020.1870087] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Mutations in the voltage-gated sodium channel Nav1.7 are linked to human pain. The Nav1.7/N1245S variant was described before in several patients suffering from primary erythromelalgia and/or olfactory hypersensitivity. We have identified this variant in a pain patient and a patient suffering from severe and life-threatening orthostatic hypotension. In addition, we report a female patient suffering from muscle pain and carrying the Nav1.7/E1139K variant. We tested both Nav1.7 variants by whole-cell voltage-clamp recordings in HEK293 cells, revealing a slightly enhanced current density for the N1245S variant when co-expressed with the β1 subunit. This effect was counteracted by an enhanced slow inactivation. Both variants showed similar voltage dependence of activation and steady-state fast inactivation, as well as kinetics of fast inactivation, deactivation, and use-dependency compared to WT Nav1.7. Finally, homology modeling revealed that the N1245S substitution results in different intramolecular interaction partners. Taken together, these experiments do not point to a clear pathogenic effect of either the N1245S or E1139K variant and suggest they may not be solely responsible for the patients’ pain symptoms. As discussed previously for other variants, investigations in heterologous expression systems may not sufficiently mimic the pathophysiological situation in pain patients, and single nucleotide variants in other genes or modulatory proteins are necessary for these specific variants to show their effect. Our findings stress that biophysical investigations of ion channel mutations need to be evaluated with care and should preferably be supplemented with studies investigating the mutations in their context, ideally in human sensory neurons.
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Affiliation(s)
- Kim Le Cann
- Institute of Physiology, RWTH Aachen University Hospital , Aachen, Germany
| | - Jannis E Meents
- Institute of Physiology, RWTH Aachen University Hospital , Aachen, Germany
| | | | - Maike F Dohrn
- Department of Neurology, Medical Faculty, RWTH Aachen University Hospital , Aachen, Germany
| | - Raya Bott
- Institute of Physiology, RWTH Aachen University Hospital , Aachen, Germany
| | - Andrea Maier
- Department of Neurology, Medical Faculty, RWTH Aachen University Hospital , Aachen, Germany
| | - Martin Bialer
- Division of Clinical Metabolism of Medical Genetics and Human Genomics at Northwell Health System , New-York, United States
| | - Petra Hautvast
- Institute of Physiology, RWTH Aachen University Hospital , Aachen, Germany
| | - Andelain Erickson
- Institute of Physiology, RWTH Aachen University Hospital , Aachen, Germany
| | - Roman Rolke
- Department for Palliative Care, Medical Faculty, RWTH Aachen University , Aachen, Germany
| | - Markus Rothermel
- Department of Chemosensation, AG Neuromodulation, Institute for Biology II, RWTH Aachen University , Aachen, 52074, Germany
| | - Jannis Körner
- Institute of Physiology, RWTH Aachen University Hospital , Aachen, Germany.,Department of Anaesthesiology, Medical Faculty, RWTH Aachen University , Aachen, Germany
| | - Ingo Kurth
- Institute of Human Genetics, Medical Faculty, RWTH Aachen University Hospital , Aachen, Germany
| | - Angelika Lampert
- Institute of Physiology, RWTH Aachen University Hospital , Aachen, Germany
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Suzuki M, Watari T. Erythromelalgia Caused by Polycythemia Vera Combined with Primary Aldosteronism. Eur J Case Rep Intern Med 2020; 7:001852. [PMID: 33194862 DOI: 10.12890/2020_001852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/13/2020] [Indexed: 11/05/2022] Open
Abstract
A 61-year-old woman with a history of primary aldosteronism caused by unilateral hyperplasia of the adrenal gland presented with a 2-week history of redness and severe pain in the right thumb and thenar regions. She had initially visited a dermatologist and was diagnosed with cellulitis and treated with cefditoren pivoxil for 5 days, but there was no improvement. The pain worsened and was accompanied by a burning sensation. The dermatologist prescribed famciclovir for 5 days owing to suspicion of herpes zoster. The patient was then referred to our department because her symptoms persisted. Physical examination showed no abnormalities other than the redness in the right thumb and thenar regions and spontaneous moderate pain present throughout the right thumb. Investigations revealed normal blood chemistry and coagulation factor levels, except for elevated haemoglobin (18.2 g/dl). Further investigations revealed an erythropoietin level of 2.3 IU/ml and Janus kinase 2 mutation. Hence, we diagnosed the patient with erythromelalgia caused by polycythemia vera. In this report, we discuss the treatment of polycythemia causing erythromelalgia, and the aetiology of primary aldosteronism and polycythemia vera. LEARNING POINTS Polycythemia can cause erythromelalgia, which should be treated with aspirin.Primary aldosteronism causes secondary erythropoiesis through activation of the renin-aldosterone system, but the mechanism is not clear.Erythropoiesis may be promoted by concurrent primary aldosteronism and polycythemia vera, resulting in secondary erythromelalgia.
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Affiliation(s)
- Morika Suzuki
- Department of General Internal Medicine, National Hospital Organization Sendai Medical Center, Miyagi, Japan
| | - Takashi Watari
- Postgraduate Clinical Training Centre, Shimane University Hospital, Shimane, Japan
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13
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Faignart N, Nguyen K, Soroken C, Poloni C, Downs HM, Laubscher B, Korff C, Oaklander AL, Roulet Perez E. Acute monophasic erythromelalgia pain in five children diagnosed as small-fiber neuropathy. Eur J Paediatr Neurol 2020; 28:198-204. [PMID: 32723684 DOI: 10.1016/j.ejpn.2020.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 05/01/2020] [Accepted: 06/08/2020] [Indexed: 02/01/2023]
Abstract
The small-fiber polyneuropathies (SFN) are a class of diseases in which the small thin myelinated (Aδ) and/or unmyelinated (C) fibers within peripheral nerves malfunction and can degenerate. SFN usually begins in the farthest, most-vulnerable axons, so distal neuropathic pain and symptoms from microvascular dysregulation are common. It is well known in adults, e.g. from diabetes, human immunodeficiency virus, or neurotoxins, but considered extremely rare in children, linked mostly with pathogenic genetic variants in voltage-gated sodium channels. However, increasing evidence suggests that pediatric SFN is not rare, and that dysimmunity is the most common cause. Because most pediatric neurologists are unfamiliar with SFN, we report the diagnosis and management of 5 Swiss children, aged 6-11y, who presented with severe paroxysmal burning pain in the hands and feet temporarily relieved by cooling-the erythromelalgia presentation. Medical evaluations revealed autoimmune diseases in 3 families and 3/5 had preceding or concomitant infections. The standard diagnostic test (PGP9.5-immunolabeled lower-leg skin biopsy) confirmed SFN diagnoses in 3/4, and autonomic function testing (AFT) was abnormal in 2/3. Blood testing for etiology was unrevealing, including genetic testing in 3. Paracetamol and ibuprofen were ineffective. Two children responded to gabapentin plus mexiletine, one to carbamazepine, two to mexiletine plus immunotherapy (methylprednisolone/IVIg). All recovered within 6 months, remaining well for years. These monophasic tempos and therapeutic responses are most consistent with acute post-infectious immune-mediated causality akin to Guillain-Barré large-fiber polyneuropathy. Skin biopsy and AFT for SFN, neuropathic-pain medications and immunotherapy should be considered for acute sporadic pediatric erythromelalgia.
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Fan X, Bu H, Wen Y, Ma L, Huang C, Xu F, Wang T, Kong C, Zhou Y. Spinal Cord Stimulation in the Treatment of Pediatric Erythromelalgia. World Neurosurg 2020; 142:388-90. [PMID: 32652278 DOI: 10.1016/j.wneu.2020.06.231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 06/27/2020] [Accepted: 06/30/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND In children, erythromelalgia is a rare but difficult to manage condition that results in bilateral episodic pain and redness in distal extremities. It is heat intolerant and relieved by cooling. Management of erythromelalgia is difficult and requires a complex multidisciplinary approach. CASE DESCRIPTION We present a case of successful treatment of erythromelalgia with short-term spinal cord stimulation in a 12-year-old girl. The patient had severe burning pain, having undergone trials of multiple medical therapies before presenting to our department. Dual-lead spinal cord stimulator electrodes were successfully implanted without complication, leading to excellent pain control, now 8 months postimplant. CONCLUSIONS This case spurs interest for future research in neuromodulation as part of the multimodal regimen to treat pediatric erythromelalgia.
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Vounotrypidis P, Pyrpasopoulou A, Sakellariou GT, Zisopoulos D, Kefala N, Oikonomou DI, Stefanis C, Aslanidis S, Bermperidis C, Pappas P. Vascular acrosyndromes in young adult population. Definition of clinical symptoms and connections to joint hypermobility. Clin Rheumatol 2019; 38:2925-2932. [PMID: 31177398 DOI: 10.1007/s10067-019-04627-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 05/24/2019] [Accepted: 05/28/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Clinical recognition of vascular acrosyndromes is often challenging. The term Raynaud's phenomenon (RP) is commonly overused to describe any form of cold-related disorder. This study aims to formally evaluate peripheral vascular symptoms affecting the population, aged ≤ 40 years, and identify any correlations to joint hypermobility (JH). PATIENTS AND METHODS Fifty patients (31 males, 19 females) with vasomotor symptoms enrolled in this five-year prospective observational study. Clinical examination by a rheumatologist and a vascular surgeon was performed along with cardiology, echocardiographic and Doppler evaluation. Patients underwent blood cell count, biochemistry, thyroid and selectively immunologic testing. Twenty-four (48%) of them performed nailfold capillaroscopy. The SPSS for Windows, v.17.0, Chicago, USA, was used for the statistical analyses. RESULTS Twenty-eight patients (56%) presented with erythromelalgia (EM), 6 (12%) with acrocyanosis (AC) and 9 (18%) as a combination of the above disorder. RP diagnosed in five (10%) while two patients (4%) presented as a mix of EM-RP. There was no correlation with abnormal laboratory tests. Increased incidence of JH was found in EM and AC patients. Among those who were tested with nailfold capillaroscopy, 75% had abnormalities ranged from mild to autoimmune-like diseases. CONCLUSIONS Erythromelalgia is the commonest functional vasculopathy in young population followed by acrocyanosis and a combination of these conditions. Joint hypermobility is markedly increased, indicating that dysautonomy may be considered the causative factor following a trigger event. Overall, RP was observed in 14% of patients. Clinical recognition of these disorders avoids unnecessary investigation. Key Points • Vascular acrosyndromes in young adults are commonly functional disorders resembling vascular algodystrophy induced by thermic stress. • Dysautonomy of joint hypermobility is the co-factor influencing the appearance of the vascular disorders. • Raynaud's phenomenon accounts to approximately 14% of vascular acrosyndromes presented in the young adult population.
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Affiliation(s)
- Periklis Vounotrypidis
- Rheumatology Department, 424 General Military Hospital, Nea Efkarpia, 56249, Thessaloniki, Greece.
| | - Athina Pyrpasopoulou
- 2nd Propaedeutic Clinic, Department of Internal Medicine, "Ippokration" Hospital, Thessaloniki, Greece
| | - Grigorios T Sakellariou
- Rheumatology Department, 424 General Military Hospital, Nea Efkarpia, 56249, Thessaloniki, Greece
| | - Dimitrios Zisopoulos
- Rheumatology Department, 424 General Military Hospital, Nea Efkarpia, 56249, Thessaloniki, Greece
| | - Nikoleta Kefala
- Rheumatology Department, 424 General Military Hospital, Nea Efkarpia, 56249, Thessaloniki, Greece
| | - Dimitrios I Oikonomou
- Department of Immunology and Microbiology, 424 General Military Hospital, Thessaloniki, Greece
| | | | - Spyros Aslanidis
- 2nd Propaedeutic Clinic, Department of Internal Medicine, "Ippokration" Hospital, Thessaloniki, Greece
| | - Charalambos Bermperidis
- Rheumatology Department, 424 General Military Hospital, Nea Efkarpia, 56249, Thessaloniki, Greece
| | - Periklis Pappas
- Vascular Surgery Department, 424 General Military Hospital, Thessaloniki, Greece
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Cardenas-de la Garza JA, Villarreal-Villarreal CD, Cuellar-Barboza A, Cardenas-Gonzalez RE, Gonzalez-Benavides N, Cruz-Gomez LG, Ocampo-Candiani J, Welsh O. Red Scrotum Syndrome Treatment with Pregabalin: A Case Series. Ann Dermatol 2019; 31:320-324. [PMID: 33911598 PMCID: PMC7992738 DOI: 10.5021/ad.2019.31.3.320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/10/2018] [Accepted: 05/11/2018] [Indexed: 12/25/2022] Open
Abstract
Red scrotum syndrome (RSS) (also known as male genital dysesthesia) is a rarely recognized entity characterized by scrotal erythema accompanied by a burning sensation, pain, hyperesthesia/dysesthesia, increased temperature and pruritus. Although its physiopathology is unknown, it has increasingly been associated with chronic topical steroid use in the male genital area. Treatment is challenging and no standardized treatment is currently available. Because current treatment relies on case reports and small case series, the need for more information about drug efficacy in RSS is warranted. The aim of this study is to describe the therapeutic response to pregabalin in patients from an outpatient dermatologic clinic in a tertiary-care hospital diagnosed with RSS. Five patients with a confirmed diagnosis of RSS were included. Ages ranged from 28 to 63 years. All patients had chronic steroid use in the genital area, mostly in the form of combined formulations of corticosteroids, antifungals, and antibiotics. Four patients were prescribed pregabalin monotherapy, 150 mg once daily at night. One patient was prescribed pregabalin and doxycycline. Two patients had complete remission after one month of therapy, one at two months and two at three months. None experienced recurrence at an average of 9.4 months' follow-up. One patient experienced morning drowsiness that did not require suspending treatment. Pregabalin is a well-tolerated and effective treatment for RSS.
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Affiliation(s)
- Jesus Alberto Cardenas-de la Garza
- Department of Dermatology, Hospital Universitario Dr. José E. González y Facultad de Medicina, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Cesar Daniel Villarreal-Villarreal
- Department of Dermatology, Hospital Universitario Dr. José E. González y Facultad de Medicina, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Adrian Cuellar-Barboza
- Department of Dermatology, Hospital Universitario Dr. José E. González y Facultad de Medicina, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Ramiro Eugenio Cardenas-Gonzalez
- Department of Dermatology, Hospital Universitario Dr. José E. González y Facultad de Medicina, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Nereyda Gonzalez-Benavides
- Department of Dermatology, Hospital Universitario Dr. José E. González y Facultad de Medicina, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Luis Gerardo Cruz-Gomez
- Department of Dermatology, Hospital Universitario Dr. José E. González y Facultad de Medicina, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Jorge Ocampo-Candiani
- Department of Dermatology, Hospital Universitario Dr. José E. González y Facultad de Medicina, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Oliverio Welsh
- Department of Dermatology, Hospital Universitario Dr. José E. González y Facultad de Medicina, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
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Huppke P, Wegener E, Gilley J, Angeletti C, Kurth I, Drenth JPH, Stadelmann C, Barrantes-Freer A, Brück W, Thiele H, Nürnberg P, Gärtner J, Orsomando G, Coleman MP. Homozygous NMNAT2 mutation in sisters with polyneuropathy and erythromelalgia. Exp Neurol 2019; 320:112958. [PMID: 31132363 DOI: 10.1016/j.expneurol.2019.112958] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 05/14/2019] [Accepted: 05/16/2019] [Indexed: 12/16/2022]
Abstract
We identified a homozygous missense mutation in the gene encoding NAD synthesizing enzyme NMNAT2 in two siblings with childhood onset polyneuropathy with erythromelalgia. No additional homozygotes for this rare allele, which leads to amino acid substitution T94M, were present among the unaffected relatives tested or in the 60,000 exomes of the ExAC database. For axons to survive, axonal NMNAT2 activity has to be maintained above a threshold level but the T94M mutation confers a partial loss of function both in the ability of NMNAT2 to support axon survival and in its enzymatic properties. Electrophysiological tests and histological analysis of sural nerve biopsies in the patients were consistent with loss of distal sensory and motor axons. Thus, it is likely that NMNAT2 mutation causes this pain and axon loss phenotype making this the first disorder associated with mutation of a key regulator of Wallerian-like axon degeneration in humans. This supports indications from numerous animal studies that the Wallerian degeneration pathway is important in human disease and raises important questions about which other human phenotypes could be linked to this gene.
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Affiliation(s)
- Peter Huppke
- Department of Pediatrics and Pediatric Neurology, University Medical Center Göttingen, Georg August University Göttingen, Germany.
| | - Eike Wegener
- Department of Pediatrics and Pediatric Neurology, University Medical Center Göttingen, Georg August University Göttingen, Germany.
| | - Jonathan Gilley
- John van Geest Centre for Brain Repair, University of Cambridge, ED Adrian Building, Forvie Site, Robinson Way, Cambridge CB2 0PY, UK; Babraham Institute, Babraham Research Campus, Babraham, Cambridge CB22 3AT, UK.
| | - Carlo Angeletti
- Department of Clinical Sciences (DISCO), Section of Biochemistry, Polytechnic University of Marche, Via Ranieri 67, 60131 Ancona, Italy.
| | - Ingo Kurth
- Institute of Human Genetics, Medical Faculty, RWTH, 52074 Aachen, Germany.
| | - Joost P H Drenth
- Department of Gastroenterology & Hepatology, Radboud UMC, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands.
| | - Christine Stadelmann
- Institute of Neuropathology, University Medical Center, Georg August University Göttingen, Germany.
| | - Alonso Barrantes-Freer
- Institute of Neuropathology, University Medical Center, Georg August University Göttingen, Germany; Department of Neuropathology, University Medical Center Leipzig, Leipzig, Germany.
| | - Wolfgang Brück
- Institute of Neuropathology, University Medical Center, Georg August University Göttingen, Germany.
| | - Holger Thiele
- Cologne Center for Genomics (CCG), University of Cologne, Cologne, Germany; Center for Molecular Medicine Cologne (CMMC), University of Cologne, 50931 Cologne, Germany.
| | - Peter Nürnberg
- Cologne Center for Genomics (CCG), University of Cologne, Cologne, Germany; Center for Molecular Medicine Cologne (CMMC), University of Cologne, 50931 Cologne, Germany.
| | - Jutta Gärtner
- Department of Pediatrics and Pediatric Neurology, University Medical Center Göttingen, Georg August University Göttingen, Germany.
| | - Giuseppe Orsomando
- Department of Clinical Sciences (DISCO), Section of Biochemistry, Polytechnic University of Marche, Via Ranieri 67, 60131 Ancona, Italy.
| | - Michael P Coleman
- John van Geest Centre for Brain Repair, University of Cambridge, ED Adrian Building, Forvie Site, Robinson Way, Cambridge CB2 0PY, UK; Babraham Institute, Babraham Research Campus, Babraham, Cambridge CB22 3AT, UK.
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18
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Wang WH, Zhang L, Dong GX, Sun TT, Lin ZM, Yang Y, Li X. Chemical lumbar sympathectomy in the treatment of recalcitrant erythromelalgia. J Vasc Surg 2018; 68:1897-1905. [PMID: 30126782 DOI: 10.1016/j.jvs.2018.05.226] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 05/24/2018] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Erythromelalgia is highly disabling and treatment is often very challenging. There have been solitary case reports that it might benefit from sympathectomy. This study sought to evaluate the short-term and long-term efficacy of chemical lumbar sympathectomy (CLS) for treatment of recalcitrant erythromelalgia and try to identify a CLS-responsive subset. METHODS Patients with recalcitrant erythromelalgia were recruited from a tertiary hospital over a 10-year period. L3 to L4 CLS was performed using 5% phenol. The pain intensity score (visual analog scale [VAS] 0-10) was assessed before CLS and at 1 day, 1 week, 3 months, 6 months, 1 year, and 2 years after CLS. A VAS decrease of 90%-100% is defined as complete response, 60%-89% as major partial response. Relapse was defined by a return of a VAS score of 5 or higher. SCN9A gene mutations were screened. RESULTS Thirteen patients were enrolled, with a median age of 15 years. The mean follow-up was 6.2 ± 3.8 years. SCN9A gene mutation was identified in five patients having family histories. The VAS was 8.2 ± 2.0 at baseline; it decreased to 4.9 ± 2.7 at 1 day and 1.9 ± 3.0 at 1 week after CLS. Nine patients (69.2%) achieved complete response at 1 week after CLS, including three patients with SCN9A gene mutation. Among the three complete response patients having the gene mutation, two reverted to major partial response and one relapsed at 2 years after CLS. Among the six complete response patients without mutation, five maintained complete response and one relapsed. Among the four patients who did not achieve complete response, one patient died at 3.5 months and one patient had an amputation performed at 4 months after CLS. CONCLUSIONS CLS provides a valid option for the treatment of recalcitrant erythromelalgia. It takes about 1 week to achieve full efficacy. Relapse may occur, especially in patients with an SCN9A gene mutation.
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Affiliation(s)
- Wen-Hui Wang
- Department of Dermatology, Peking University Third Hospital, Beijing, China
| | - Long Zhang
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing, China; Wound Healing Center, Peking University Third Hospital, Beijing, China.
| | - Guo-Xiang Dong
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing, China
| | - Ting-Ting Sun
- Department of Dermatology, Peking University Third Hospital, Beijing, China
| | - Zhi-Miao Lin
- Department of Dermatology, Peking University First Hospital, Beijing, China
| | - Yong Yang
- Department of Dermatology, Peking University First Hospital, Beijing, China
| | - Xuan Li
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing, China
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19
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Abstract
In the contemporary era of medical diagnosis via sophisticated radiographic imaging and/or comprehensive serological testing, a focused physical examination remains paramount in recognizing the cutaneous manifestations of chronic vascular disease. Recognition of the unique cutaneous signs of lymphatic and venous hypertension assists in the diagnosis as well as the staging and classification of both lymphedema and chronic venous insufficiency. Awareness of explicit dermatologic vasomotor manifestations aids not only in the identification of acrocyanosis, Raynaud phenomenon, pernio, and erythromelalgia but also mitigates confusion related to their clinical overlap. Although the clinical signs of peripheral artery disease are not necessarily specific or sensitive, a knowledge of suggestive dermatologic findings is helpful in recognition of severe limb ischemia. A brief review of the epidemiology, etiology, pathogenesis, and therapy of cutaneous related chronic vascular disease follows including an emphasis on characteristic clinical features supported by illustrative photographs.
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Affiliation(s)
- Steven M Dean
- Division of Cardiovascular Medicine, Ohio State University Wexner Medical Center, Columbus, OH.
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20
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Abstract
Erythromelalgia is a rare syndrome characterized by the intermittent or, less commonly, by the permanent occurrence of extremely painful hyperperfused skin areas mainly located in the distal extremities. Primary erythromelalgia is nowadays considered to be a genetically determined neuropathic disorder affecting SCN9A, SCN10A, and SCN11A coding for NaV1.7, NaV1.8, and NaV1.9 neuronal sodium channels. Secondary forms might be associated with myeloproliferative disorders, connective tissue disease, cancer, infections, and poisoning. Between the pain episodes, the affected skin areas are usually asymptomatic, but there are patients with typical features of acrocyanosis and/or Raynaud's phenomenon preceding or occurring in between the episodes of erythromelalgia. Diagnosis is made by ascertaining the typical clinical features. Thereafter, the differentiation between primary and secondary forms should be made. Genetic testing is recommended, especially in premature cases and in cases of family clustering in specialized genetic institutions after genetic counselling. Multimodal therapeutic intervention aims toward attenuation of pain and improvement of the patient's quality of life. For this purpose, a wide variety of nonpharmacological approaches and pharmacological substances for topical and systemic use have been proposed, which are usually applied individually in a step-by-step approach. Prognosis mainly depends on the underlying condition and the ability of the patients and their relatives to cope with the disease.
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Affiliation(s)
| | | | - Jutta Gisela Richter
- 2 Poliklinik, Funktionsbereich und Hiller Forschungszentrum für Rheumatologie, Medizinische Fakultät, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
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21
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Geha P, Schulman BR, Dib-Hajj SD, Waxman SG. Brain activity associated with pain in inherited erythromelalgia: stimulus-free pain engages brain areas involved in valuation and learning. Neurobiol Pain 2018; 3:8-14. [PMID: 31080911 PMCID: PMC6505710 DOI: 10.1016/j.ynpai.2018.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 01/15/2018] [Accepted: 01/16/2018] [Indexed: 06/09/2023]
Abstract
Inherited erythromelalgia (IEM) is a chronic pain disorder caused by gain-of-function mutations of peripheral sodium channel Nav1.7, in which warmth triggers severe pain. Little is known about the brain representation of pain in IEM. Here we study two subjects with the IEM Nav1.7-S241T mutation using functional brain imaging (fMRI). Subjects were scanned during each of five visits. During each scan, pain was first triggered using a warming boot and subjects rated their thermal-heat pain. Next, the thermal stimulus was terminated and subjects rated stimulus-free pain. Last, subjects performed a control visual rating task. Thermal-heat induced pain mapped to the frontal gyrus, ventro-medial prefrontal cortex, superior parietal lobule, supplementary motor area, insula, primary and secondary somato-sensory motor cortices, dorsal and ventral striatum, amygdala, and hippocampus. Stimulus-free pain, by contrast, mapped mainly to the frontal cortex, including dorsal, ventral and medial prefrontal cortex, and supplementary motor area. Examination of time periods when stimulus-free pain was changing showed further activations in the valuation network including the rostral anterior cingulate cortex, striatum and amygdala, in addition to brainstem, thalamus, and insula. We conclude that, similar to other chronic pain conditions, the brain representation of stimulus-free pain during an attack in subjects with IEM engages brain areas involved in acute pain as well as valuation and learning.
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Affiliation(s)
- Paul Geha
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06511, United States
- The John B. Pierce Laboratory, New Haven CT 06519, United States
| | - Betsy R. Schulman
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06510, United States
- Neurorehabilitation Research Center, Veterans Affairs Hospital, West Haven, CT 06516, United States
| | - Sulayman D. Dib-Hajj
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06510, United States
- Neurorehabilitation Research Center, Veterans Affairs Hospital, West Haven, CT 06516, United States
| | - Stephen G. Waxman
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06510, United States
- Neurorehabilitation Research Center, Veterans Affairs Hospital, West Haven, CT 06516, United States
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22
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Schrenk-Siemens K, Rösseler C, Lampert A. Translational Model Systems for Complex Sodium Channel Pathophysiology in Pain. Handb Exp Pharmacol 2018; 246:355-69. [PMID: 29374838 DOI: 10.1007/164_2017_91] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Chronic pain patients are often left with insufficient treatment as the pathophysiology especially of neuropathic pain remains enigmatic. Recently, genetic variations in the genes of the voltage-gated sodium channels (Navs) were linked to inherited neuropathic pain syndromes, opening a research pathway to foster our understanding of the pathophysiology of neuropathic pain. More than 10 years ago, the rare, inherited pain syndrome erythromelalgia was linked to mutations in the subtype Nav1.7, and since then a plethora of mutations and genetic variations in this and other Nav genes were identified. Often the biophysical changes induced by the genetic alteration offer a straightforward explanation for the clinical symptoms, but mutations in some channels, especially Nav1.9, paint a more complex picture. Although efforts were undertaken to significantly advance our knowledge, translation from heterologous or animal model systems to humans remains a challenge. Here we present recent advances in translation using stem cell-derived human sensory neurons and their potential application for identification of better, effective, and more precise treatment for the individual pain patient.
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Abstract
Essential thrombocytosis (ET) has rarely been reported with autoimmune rheumatic disorders. We report a case of young female, diagnosed case of Rheumatoid arthritis (RA), who had been overlooked for her raised platelet counts. Later her symptoms of impending digital gangrene led to an active search for her thrombocytosis. JAK2 mutation came out to be positive and she was diagnosed as ET associated with RA. She was treated with Hydroxyurea and Aspirin, in addition to her RA treatment. Patient responded well to the treatment and her platelet counts have been gradually improved, however, she developed gangrene of toe, for which amputation of distal phalanx of toe and nail excision was done, later in the disease course.
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Affiliation(s)
- Waleed Azam
- Dr. Waleed Azam, MBBS, FCPS Trainee. Medicine Department, Patel Hospital, ST-18, Block-4, Gulshan-e-Iqbal, Karachi, Pakistan
| | - Uzma Erum
- Dr. Uzma Erum, MBBS, FCPS (Medicine). Medicine Department, Patel Hospital, ST-18, Block-4, Gulshan-e-Iqbal, Karachi, Pakistan,Correspondence: Dr. Uzma Erum, Senior Registrar, Medicine Department, Patel Hospital, ST-18, Block-4, Gulshan-e-Iqbal, Karachi, Pakistan. E-mail:
| | - Asif Jan Muhammad
- Dr. Asif Jan Muhammad, MBBS, MCPS, MRCP (UK). Medicine Department, Patel Hospital, ST-18, Block-4, Gulshan-e-Iqbal, Karachi, Pakistan
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Michiels JJ. Aspirin cures erythromelalgia and cerebrovascular disturbances in JAK2-thrombocythemia through platelet-cycloxygenase inhibition. World J Hematol 2017; 6:32-54. [DOI: 10.5315/wjh.v6.i3.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 04/27/2017] [Accepted: 07/17/2017] [Indexed: 02/05/2023] Open
Abstract
Hypersensitive (sticky) platelets in JAK2-mutated essential thrombocythemia (ET) and polycythemia vera (PV) with thrombocythemia spontaneously activate at high shear in arterioles, secrete their inflammatory prostaglandin endoperoxides and induce platelet-mediated arteriolar fibromuscular intimal proliferation. Constitutively activated JAK2 mutated hypersensitive (sticky) platelets spontaneously aggregate at high shear in the endarteriolar circulation as the cause of aspirin responsive erythromelalgia and platelet arterial thrombophilia in JAK2-mutated thrombocythemia patients. Increased production of prostglandin endoperoxides E2 and thromboxane A2 released by activated sticky platelets in arterioles account for redness warmth and swelling of erythromelalgia and platelet derived growth factor can readily explain the arteriolar fibromuscular intimal proliferation. Von Willebrand factor (VWF) platelet rich occlusive thrombi in arterioles are the underlying pathobiology of erythromelalgic acrocyanosis, migraine-like transient cerebral attacks (MIAs), acute coronary syndromes and abdominal microvscular ischemic events. Irreversible platelet cyco-oxygenase inhibition by aspirin cures the erythromelalgia, MIAs and microvascular events, corrects shortened platelet survival to normal, and returns increased plasma levels of beta-TG, platelet factor 4, thrombomoduline and urinary thromboxane B2 excretion to normal in symptomatic JAK2-thrombocythemia patients. In vivo activation of sticky platelets and VWF-platelet aggregates account for endothelial cell activation to secrete thrombomoduline and sVCAM followed by occlusion of arterioles by VWF-rich platelet thrombi in patients with erythromelalgic thrombotic thrombocythemia (ETT) in ET and PV patients. ETT is complicated by spontaneous hemorrhagic thrombocythemia (HT) or paradoxical ETT/HT due to acquired von Willebrand disease type 2A at platelet counts above 1000 × 109/L and disappears by cytoreduction of platelets to normal (< 400 × 109/L).
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Adamec I, Lakoš Jukić I, Habek M. Erythromelalgia as a manifestation of autonomic nervous system involvement in multiple sclerosis. Mult Scler Relat Disord 2016; 8:1-3. [PMID: 27456866 DOI: 10.1016/j.msard.2016.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 03/05/2016] [Accepted: 04/09/2016] [Indexed: 10/21/2022]
Abstract
Erythromelalgia is a rare condition characterized by burning pain, erythema and increased temperature of the hands or the feet. Its etiology is not completely understood but it is believed that the underlying cause is a peripheral vascular dysfunction that leads to simultaneous tissue hypoxia and hyperemia. We present a rare co-occurrence of erythromelalgia and multiple sclerosis in a patient with autonomic nervous system dysfunction and propose a causative interconnection.
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Affiliation(s)
- Ivan Adamec
- University Hospital Center Zagreb, Department of Neurology, Referral Center for Autonomic Nervous System Disorders, Zagreb, Croatia.
| | - Ines Lakoš Jukić
- University Hospital Center Zagreb, Department of Dermatology and Venereology, Zagreb, Croatia
| | - Mario Habek
- University Hospital Center Zagreb, Department of Neurology, Referral Center for Autonomic Nervous System Disorders, Zagreb, Croatia; School of Medicine, University of Zagreb, Zagreb, Croatia
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Abstract
CONTEXT Paralepistopsis acromelalga, formerly known as Clitocybe acromelalga, is a rare poisonous mushroom. The mycotoxins in this mushroom cause symptoms resembling those of erythromelalgia; however, its pathogenesis remains unclear. In this report, a patient who received nicotinic acid treatment for P. acromelalga poisoning and radiological evaluation for erythromelalgia has been presented. Case detail: A 59-year-old woman was hospitalized for redness, swelling, and burning pain in her extremities that rendered difficulty in walking, and a diagnosis of P. acromelalga poisoning was made by detailed interview and mushroom identification. She was treated with intravenous nicotinic acid for 17 days followed by oral nicotinic acid amide for 2 months. She exhibited rapid symptomatic improvement and walked independently after 11 days of initial treatment. Initial MRI of her feet revealed toe-dominated subcutaneous thickening. After nicotinic acid treatment, those radiological findings improved dramatically. DISCUSSION The subcutaneous thickening evident on MRI indicated P. acromelalga poisoning-induced erythromelalgia involved subcutaneous inflammatory edema. The typical duration of edema without treatment is more than a month. The improvement on MRI after nicotinic acid treatment indicated that the adequate vasodilation induced by nicotinic acid contributed to resolution of the symptoms. Nicotinic acid was associated with the improvement of the edematous changes caused by the P. acromelalga intoxication.
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Affiliation(s)
- Nobuhito Nakajima
- a Department of Neurology , Kitamurayama Hospital , Yamagata , Japan
| | - Masayuki Ueda
- b Department of Neurology and Stroke Medicine , Tokyo Metropolitan Tama Medical Center , Tokyo , Japan
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27
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Abstract
Vascular acrosyndromes are associated with vasomotor disorders. They may be paroxysmal, like Raynaud's phenomenon, whitening of the fingers on exposure to cold, or erythromelalgia, a painful form of erythema induced by exposure to heat. Others are permanent or semi-permanent, such as acrocyanosis, chilblains, spontaneous haematoma of the fingers, acrocholose and digital ischaemia or necrosis. Diagnosis of the type of acrosyndrome at issue is based primarily on clinical examination and history-taking. Capillaroscopy and antinuclear antibody assay are key examinations essential for distinguishing between primary and secondary Raynaud's phenomenon and connective tissue disorders. Complete blood counts, screening for thyroid dysthyroidism, and antinuclear antibody assay can help distinguish between primary erythromelalgia and erythromelalgia secondary to a systemic disease, principally myeloproliferative syndrome. In the case of acrocyanosis, spontaneous digital haematomas and typical bilateral chilblains, examinations are of no value. For the other permanent and semi-permanent acrosyndromes such as digital ischaemia and purpuric or livedoid lesions, screening for arterial or thrombotic disease is necessary.
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Affiliation(s)
- P Senet
- Service de dermatologie, UF de dermatologie vasculaire, hôpital Tenon, 4, rue de la Chine, 75970 Paris cedex 20, France.
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28
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Abstract
Hansen's disease, though considered to be at the verge of elimination in many countries including India, still continues to surprise patients and dermatologists alike. This is mainly due to its varying and unconventional presentations which may lead to initial misdiagnosis and prolongation of treatment. Here we describe an unusual case presenting with erythematous photosensitive facial lesions associated with erythromelalgia of the finger tips, provisionally diagnosed as SLE. A subsequent histopathology examination proved it to be Hansens’ disease Borderline Tuberculoid variety. Hansen's disease can be termed as the modern great imitator, displacing the traditional great imitator, syphilis.
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Affiliation(s)
- Shenoi Shrutakirthi Damodar
- Department of Dermatology and Venereology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Prabhu Smitha
- Department of Dermatology and Venereology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Balakrishnan Nirmal
- Department of Dermatology and Venereology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Nayak U K Sudhir
- Department of Dermatology and Venereology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Pai Sathish Ballambat
- Department of Dermatology and Venereology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
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29
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Kashif AW, Aggarwal S, Verma T, Gupta RM. JAK2 V617F negative essential thrombocythemia. Med J Armed Forces India 2014; 69:294-6. [PMID: 24600127 DOI: 10.1016/j.mjafi.2012.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 09/02/2012] [Indexed: 10/27/2022] Open
Affiliation(s)
- A W Kashif
- Graded Specialist (Pathology), Command Hospital (NC), C/O 56 APO, India
| | - Sameer Aggarwal
- Classified Specialist (Pathology), Command Hospital (NC), C/O 56 APO, India
| | - Tarun Verma
- Classified Specialist (Med & Clinical Haematology), Command Hospital (CC), Lucknow, UP, India
| | - R M Gupta
- Senior Advisor (Path & Microbiology), Command Hospital (NC), C/O 56 APO, India
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30
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Eberhardt M, Nakajima J, Klinger AB, Neacsu C, Hühne K, O'Reilly AO, Kist AM, Lampe AK, Fischer K, Gibson J, Nau C, Winterpacht A, Lampert A. Inherited pain: sodium channel Nav1.7 A1632T mutation causes erythromelalgia due to a shift of fast inactivation. J Biol Chem 2014; 289:1971-80. [PMID: 24311784 PMCID: PMC3900947 DOI: 10.1074/jbc.m113.502211] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 11/26/2013] [Indexed: 11/06/2022] Open
Abstract
Inherited erythromelalgia (IEM) causes debilitating episodic neuropathic pain characterized by burning in the extremities. Inherited "paroxysmal extreme pain disorder" (PEPD) differs in its clinical picture and affects proximal body areas like the rectal, ocular, or jaw regions. Both pain syndromes have been linked to mutations in the voltage-gated sodium channel Nav1.7. Electrophysiological characterization shows that IEM-causing mutations generally enhance activation, whereas mutations leading to PEPD alter fast inactivation. Previously, an A1632E mutation of a patient with overlapping symptoms of IEM and PEPD was reported (Estacion, M., Dib-Hajj, S. D., Benke, P. J., Te Morsche, R. H., Eastman, E. M., Macala, L. J., Drenth, J. P., and Waxman, S. G. (2008) NaV1.7 Gain-of-function mutations as a continuum. A1632E displays physiological changes associated with erythromelalgia and paroxysmal extreme pain disorder mutations and produces symptoms of both disorders. J. Neurosci. 28, 11079-11088), displaying a shift of both activation and fast inactivation. Here, we characterize a new mutation of Nav1.7, A1632T, found in a patient suffering from IEM. Although transfection of A1632T in sensory neurons resulted in hyperexcitability and spontaneous firing of dorsal root ganglia (DRG) neurons, whole-cell patch clamp of transfected HEK cells revealed that Nav1.7 activation was unaltered by the A1632T mutation but that steady-state fast inactivation was shifted to more depolarized potentials. This is a characteristic normally attributed to PEPD-causing mutations. In contrast to the IEM/PEPD crossover mutation A1632E, A1632T failed to slow current decay (i.e. open-state inactivation) and did not increase resurgent currents, which have been suggested to contribute to high-frequency firing in physiological and pathological conditions. Reduced fast inactivation without increased resurgent currents induces symptoms of IEM, not PEPD, in the new Nav1.7 mutation, A1632T. Therefore, persistent and resurgent currents are likely to determine whether a mutation in Nav1.7 leads to IEM or PEPD.
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Affiliation(s)
- Mirjam Eberhardt
- From the Institute of Physiology and Pathophysiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitatsstrasse 17, 91054 Erlangen, Germany
- the Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover
| | - Julika Nakajima
- the Department of Human Genetics Friedrich-Alexander Universität Erlangen-Nürnberg, Schwabachanlage 10, 91054 Erlangen, Germany
| | - Alexandra B. Klinger
- From the Institute of Physiology and Pathophysiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitatsstrasse 17, 91054 Erlangen, Germany
| | - Cristian Neacsu
- From the Institute of Physiology and Pathophysiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitatsstrasse 17, 91054 Erlangen, Germany
| | - Kathrin Hühne
- the Department of Human Genetics Friedrich-Alexander Universität Erlangen-Nürnberg, Schwabachanlage 10, 91054 Erlangen, Germany
| | - Andrias O. O'Reilly
- From the Institute of Physiology and Pathophysiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitatsstrasse 17, 91054 Erlangen, Germany
| | - Andreas M. Kist
- From the Institute of Physiology and Pathophysiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitatsstrasse 17, 91054 Erlangen, Germany
| | - Anne K. Lampe
- the South East of Scotland Clinical Genetic Service, Western General Hospital, Edinburgh EH4 2XU, United Kingdom
| | - Kerstin Fischer
- the Department of Anesthesiology Friedrich-Alexander Universität Erlangen-Nürnberg, Krankenhausstrasse 12, 91054 Erlangen, Germany
| | - Jane Gibson
- the Fife Rheumatic Diseases Unit, Whyteman's Brae Hospital, Kirkcaldy, KY1 2ND, United Kingdom
| | - Carla Nau
- the Department of Anesthesiology Friedrich-Alexander Universität Erlangen-Nürnberg, Krankenhausstrasse 12, 91054 Erlangen, Germany
- the Department of Anesthesiology and Intensive Care, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany, and
| | - Andreas Winterpacht
- the Department of Human Genetics Friedrich-Alexander Universität Erlangen-Nürnberg, Schwabachanlage 10, 91054 Erlangen, Germany
| | - Angelika Lampert
- From the Institute of Physiology and Pathophysiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitatsstrasse 17, 91054 Erlangen, Germany
- the Institute of Physiology, Rheinisch-Westfälische Technische Hochschule Aachen University, Paulwelsstrasse 30, 52074 Aachen, Germany
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Luo DQ, Zhao YK, Xu QF, He XQ, Wu LC. Recurrent facial erythema with burning sensation and increased temperature: a variant of erythromelalgia or a new entity? Pain Med 2014; 15:1007-10. [PMID: 24433512 DOI: 10.1111/pme.12343] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Erythromelalgia is a rare clinical syndrome characterized by episodic attacks of burning pain, erythema, and increased temperature, primarily affecting the extremities, and in rare instances, involving the ear, face, neck, and the scrotum. The dermatoscopic features of erythromelalgia in a case with solely facial involvement have never been described previously. OBSERVATIONS We describe a 14-year-old female who presented with erythema, burning sensation, and warmth on her face only, which mimic the features of erythromelalgia. Physical examination showed higher temperature on the involved cheeks than on axillas during the episode, while the temperature on both areas was the same between episodes. Dermatoscope showed more dilated vessels inside the erythema during the episodes than between the episodes. The symptoms had excellent response to the combination treatment of gabapentin, indomethacin, and topical lidocaine compounds. CONCLUSIONS The present case is considered to be a variant of erythromelalgia. Its erythema may be resulted from the dilated vessels. Combination of modalities may provide effective management for erythromelalgia. "Erythermalgia" may be better than "erythromelalgia" to describe such conditions.
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Affiliation(s)
- Di-Qing Luo
- Department of Dermatology, Huangpu Hospital of The First Affiliated Hospital
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32
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Michiels JJ, Ten Kate FWJ, Koudstaal PJ, Van Genderen PJJ. Aspirin responsive platelet thrombophilia in essential thrombocythemia and polycythemia vera. World J Hematol 2013; 2:20-43. [DOI: 10.5315/wjh.v2.i2.20] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2012] [Accepted: 01/06/2013] [Indexed: 02/05/2023] Open
Abstract
Essential thrombocythemia (ET) and polycythemia vera (PV) frequently present with erythromelalgia and acrocyanotic complications, migraine-like microvascular cerebral and ocular transient ischemic attacks (MIAs) and/or acute coronary disease. The spectrum of MIAs in ET range from poorly localized symptoms of transient unsteadiness, dysarthria and scintillating scotoma to focal symptoms of transient monocular blindness, transient mono- or hemiparesis or both. The attacks all have a sudden onset, occur sequentially rather than simultaneously, last for a few seconds to several minutes and are usually associated with a dull, pulsatile or migraine-like headache. Increased hematocrit and blood viscosity in PV patients aggravate the microvascular ischemic syndrome of thrombocythemia to major arterial and venous thrombotic complications. Phlebotomy to correct hematocrit to normal in PV significantly reduces major arterial and venous thrombotic complications, but fails to prevent the platelet-mediated erythromelalgia and MIAs. Complete long-term relief of the erythromelalgic microvascular disturbances, MIAs and major thrombosis in ET and PV patients can be obtained with low dose aspirin and platelet reduction to normal, but not with anticoagulation. Skin punch biopsies from the erythromelalgic area show fibromuscular intimal proliferation of arterioles complicated by occlusive platelet-rich thrombi leading to acrocyanotic ischemia. Symptomatic ET patients with erythromelalgic microvascular disturbances have shortened platelet survival, increased platelet activation markers β-thromboglobulin (β-TG), platelet factor 4 (PF4) and thrombomoduline (TM), increased urinary thromboxane B2 (TXB2) excretion, and no activation of the coagulation markers thrombin fragments F1+2 and fibrin degradation products. Inhibition of platelet cyclooxygenase (COX1) by aspirin is followed by the disappearance and no recurrence of microvascular disturbances, increase in platelet number, correction of the shortened platelet survival times to normal, and reduction of increased plasma levels of β-TG, PF4, TM and urinary TXB2 excretion to normal. These results indicate that platelet-mediated fibromuscular intimal proliferation and platelet-rich thrombi in the peripheral, cerebral and coronary end-arterial microvasculature are responsible for the erythromelalgic ischemic complications, MIAs and splanchnic vein thrombosis. Baseline platelet P-selectin levels and arachidonic acid induced COX1 mediated platelet activation showed a highly significant increase of platelet P-selectin expression (not seen in ADP and collagen stimulated platelets), which was significantly higher in JAK2V617F mutated compared to JAK2 wild type ET.
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33
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Abstract
Adult-onset erythromelalgia (EM) is a rare disease characterized by episodic bouts of burning pain and erythema for which the optimal therapy is unclear. In this report, we describe a 68-year-old Japanese woman with adult-onset EM. Intravenous administration of methylprednisolone sodium succinate 1,000 mg/day dramatically improved her pain as evaluated by the visual analog scale. Although the patient's pain gradually developed again, it could be controlled with pregabalin. Our present case might suggest a possible, optimal therapy for adult-onset EM.
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Affiliation(s)
- Aya Kakizaki
- Department of Dermatology, Tohoku University Graduate School of Medicine, Sendai, Japan
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34
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Gambichler T, Matip R. Erythromelalgia and livedo reticularis in a patient with essential thrombocythemia, acquired von Willebrand disease, and elevated anti-phospholipid antibodies. Ann Dermatol 2012; 24:214-7. [PMID: 22577276 PMCID: PMC3346916 DOI: 10.5021/ad.2012.24.2.214] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 05/23/2011] [Accepted: 06/01/2011] [Indexed: 11/08/2022] Open
Abstract
Essential thrombocythemia (ET) is a clonal stem cell disease characterized by isolated thrombocytosis and thrombohemorrhagic complications. We describe an unusual case of ET primarly presenting with skin symptoms including erythromelalgia and livedo reticularis (racemosa-type). Persistent thrombocytosis, bone marrow findings, JAK2 gene mutation, and markedly decreased ristocetin-cofactor activity were consistent with the diagnosis of ET and acquired von Willebrand disease. Elevated antiphospholipid antibodies were also found. The present case highlights the complex nature and diagnostic challenge of myeloproliferative disorders such as ET, which can involve multiple organ systems and often shows a variety of microvascular complications, coagulation anomalies, and autoimmune phenomena.
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Affiliation(s)
- Thilo Gambichler
- Department of Dermatology, Ruhr-University Bochum, Bochum, Germany.
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35
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Dicks K, Rizek P. Massage therapy techniques as pain management for erythromelalgia: a case report. Int J Ther Massage Bodywork 2010; 3:5-9. [PMID: 21589683 PMCID: PMC3088525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Erythromelalgia is characterized by temperature-dependent redness, pain, and warmth in one or more extremities. It may be a primary disease, or it may occur secondarily because of underlying illness. It is a chronic, debilitating condition often resistant to medical treatment. PURPOSE The present report evaluates massage as a complementary therapy to reduce pain and other symptoms associated with erythromelalgia. PARTICIPANT A 31-year-old female with a long-standing history of erythromelalgia bilaterally in the lower extremities presented with complaints of acute pain exacerbation, anxiety, decreased quality of sleep, and difficulty with activities of daily living for prolonged periods of time. She had no previous experience with massage therapy or any other complementary therapies. INTERVENTION Massage therapy was introduced over the course of 9 treatments, each 1 hour in duration, using various massage therapy techniques, remedial exercise, and recommended home care. RESULTS In this patient with erythromelalgia, effleurage and petrissage as massage therapy techniques provided temporary pain relief in the lower extremities and long-term benefits that relieved anxiety, which improved restorative sleep and increased the patient's participation in activities of daily living. CONCLUSIONS For this treatment protocol, therapist observation and patient feedback suggest that massage therapy may lead to a state of increased relaxation, decreased stress, decreased muscle tension, and improved sleep. These positive effects may have an indirect role in the ability of the patient to cope with erythromelalgia day to day.
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Affiliation(s)
- Krista Dicks
- Barrie, ON, Canada,Corresponding author: Krista Dicks, Barrie, ON Canada.,
| | - Philippe Rizek
- University of Western Ontario, London, and Canadian Society for Life Science Research, Toronto, ON, Canada
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