Combined testing of autonomic and sensory dysfunction in patients with unilateral facial flushing and sweating during exercise

Abstract

Patients with unilateral facial flushing are occasionally referred to clinical neurophysiological evaluation with the question of the site of lesion. These patients may have a mixture of autonomic and sensory symptoms. We wanted to study to which extent a combined autonomic and sensory clinical neurophysiological testing before and after exercise may help in the diagnostic evaluation of the patients. Five patients were investigated at rest with quantitative sensory thresholds (QST, measurement of thermal thresholds) and quantitative sudomotor axon reflex test (QSART) in all extremities. Sweet volumes (QSWEAT) and skin temperatures were then measured after 30 to 60 minutes of exercise. Marked side-to-side differences were observed for QST and QSART at rest as well as for QSWEAT and skin temperatures following exercise, in accordance with the patients' symptoms. However, asymptomatic abnormal findings were also demonstrated in the feet of four patients, following both crossed and non-crossed distributions. EMG/neurography and MRI-findings were normal in all patients and no aetiological explanations were found. Combined autonomic and sensory testing including the legs provided evidence of unexpectedly more widespread abnormalities, including asymptomatic findings. Although the patients presented with seemingly similar symptoms, there was a striking heterogeneity in their results, suggesting different sites of dysfunction. An extracranial lesion was considered likely in one or maybe two patients, while the possibility of a central lesion had to be considered in the three other patients.