Hereditary sensory and autonomic neuropathies: types II, III, and IV

Clinical presentation

HSAN II presents in infancy or early childhood and is nonprogressive. It is characterized by profound and universal sensory loss and marked hypotonia. HSAN II occurs sporadically or with autosomal recessive inheritance. There is no sex preference or particular ethnic preponderance, and to date there is no increased incidence of consanguinity.

Although the disorder is associated with profound sensory loss involving large and small fiber modalities, the earliest problems are caused by autonomic dysfunction [1–3, 15–17]. The neonatal course is characterized by severe feeding problems and frequent apnea [15–17]. Gastroesophageal reflux occurs commonly. Other autonomic disturbances, such as erythematous blotching of the skin and postural hypotension, have not been observed. Episodic hyperhydrosis as well as patchy areas of anhidrosis can occur in the same patient. Overflow tearing is frequently delayed but is eventually normal. Pupils have an exaggerated response to parasympathomimetic agents.

All peripheral sensations are affected but distribution of somatic involvement may vary. Pain, temperature, and position senses are involved. Trophic changes are present in the upper and lower extremities. At one time, HSAN II was termed 'Morvan's disease' (after the physician who first described the disease and the occurrence of 'painless whitlows' or acrodystrophic neuropathy [18, 19]. HSAN II is associated with frequent occurrence of unrecognized injuries and fractures of hands, feet, and limbs, as well as Charcot joints [1, 17, 19].

Selfmutilation may begin as early as four months of age and is usually associated with eruption of primary dentition [20]. Taste sensation is diminished and lingual fungiform papillae are hypotrophic. Corneal and gag reflexes may be diminished. Deep tendon reflexes are attenuated and hypotonia is common which delays attainment of developmental milestones and may contribute to scoliosis. Despite the marked sensory abnormalities, other aspects of the neurological examination may be normal including mental function, cranial nerves, cerebellar and motor functions. Although the tendon reflexes are decreased or absent, there is no muscle atrophy or muscle weakness.

Pathology

Sural nerve biopsy reveals a marked reduction in nerve size and depletion of large and small myelinated fibers but only a slightly decreased number of unmyelinated fibers [16, 19]. No cutaneous sensory receptors or nerve fibers are seen but catecholaminergic sympathetic fibers can be demonstrated by aldehydeinduced fluorescence [19].

Diagnosis

As there is no DNA molecular testing available, diagnosis is based on documenting profound peripheral sensory involvement of both peripheral and cranial nerves, which includes an absent axon flare after intradermal histamine. Clinical identification is made by the finding of a mutilating acropathy with a severe, distally pronounced impairment of all sensory qualities that includes light touch sensation, position sense and vibratory perception, as well as pain and temperature perception. Supportive evidence includes selfmutilation, hypotonia and delayed milestones, and normal somatic growth.

The neurophysiological evaluation shows abnormal vibratory thresholds, and quantitative sensory testing may also reveal elevated thermal thresholds at the hands and feet [16]. Typically, nerve conduction studies confirm severe impairment of sensory nerve conduction velocities and absent sensory nerve action potentials, but motor nerve conduction velocities are at or slightly below the normal limit and compound motor action potentials may only have slightly reduced amplitudes [16, 19]. According to Dyck, the electromyogram (EMG) shows minimal fibrillations and a rarified pattern with maximal volitional innervation as well as an increased number of polyphasic motor action unit potentials [16]. Electroencephalographic (EEG) studies are normal, but auditory evoked potentials indicate immature pathways.

Management

Management is symptomatic and preventative. If feeding problems compromise nutrition and if gastroesophageal reflux is also present, fundoplication with gastrostomy is recommended. Sleep pneumograms can determine if there is central apnea and if respiratory support is needed. Parents and patients education is required to learn how to avoid injury and to be alert for signs of unrecognized trauma.

Clinical Presentation

HSAN III is the most common of the HSAN disorders. It is present at birth and it is progressive [21, 22]. Because the effects of the autonomic nervous system are pervasive, there are protean secondary functional abnormalities that result in multisysytem dysfunction. Clinical expression varies widely from individual to individual as does disease progression, even within the same family. The child with familial dysautonomia is not born with any obvious dysmorphism but a characteristic facial expression may develop over time that appears to be due to the effects of facial tone on bone development. The facies appear more similar with advancing age and there is a curious flattening of the upper lip that is most obvious when smiling (Figure 2). Other common physical characteristics are due to orthopedic problems such as severe kyphoscoliosis and short stature (Figure 3).

Autonomic manifestations are prominent, involve peripheral and central tracts, and impose the greatest impediments to function [22]. Although absence of tears (alacrima) with emotional crying is one of the cardinal features of the disorder, this sign may not be immediately recognized since lack of overflow tears is normal until about seven months of age. Thus the earliest sign of autonomic dysfunction usually is feeding difficulties. Oral incoordination results in a poor suck and misdirection of the bolus and gastroesophageal reflux cause recurrent aspiration pneumonia that can result eventually in chronic lung disease. Compounding the problem of aspiration pneumonias and chronic lung disease is the presence of relative insensitivity to hypoxemia [23–26], which limits ability to cope with pneumonia or even travel to high altitudes where there is reduced partial pressure of oxygen. Ensuing hypoxemia may lead to hypotension, bradyarrhythmia and even syncope. FD patients also exhibit protracted episodes of nausea and vomiting that are termed the 'dysautonomic crisis', a constellation of symptoms with abnormal gastrointestinal motility being only one aspect. During the crisis there are cardiovascular changes including hypertension, tachycardia and blotching. There is a generalized increase in secretions resulting in excessive diaphoresis, gastrorrhea, bronchorrhea and hypersalivation with copious drooling. In addition there are negative personality changes that can range from irritability and withdrawal to general excitation with pacing and picking at the skin. Forty percent of individuals with FD manifest a cyclical crisis pattern with frequencies that can occur daily, weekly, or monthly. In these individuals the crisis is most likely to follow morning arousal. However, with sufficient stress, a crisis can be observed in any affected individual. The stress can be emotional secondary to anxiety or the stress can be physiologic secondary to infection, surgery, sleep deprivation, excessive fatigue, or visceral pain secondary to constipation or menses.

The individual with familial dysautonomia commonly experiences orthostatic hypotension without a compensatory tachycardia, as well as episodic and supine hypertension [22, 27]. Orthostatic change in blood pressure is a cardinal sign of autonomic insufficiency. In FD individuals, the lack of compensatory tachycardia is believed due to decreased sympathetic innervation of the vasculature with subsequent inability to increase plasma norepinephrine in response to standing or exercise [28]. Clinical manifestations of orthostatic hypotension include presyncope: episodes of lightheadedness, dizzy spells, and blurring of vision. Some patients complain of "weak legs." On occasion, there may be syncope. Symptoms tend to be worse in the morning, in hot or humid weather, when the bladder is full, before a large bowel movement, after a long car ride, coming out of a movie theater, or with fatigue. Infection and dehydration can compound symptoms. Generally, low blood pressure is more troublesome in the adult years and can greatly limit function and mobility.

The dysautonomic patient can also experience episodic hypertension in response to emotional stress or visceral pain or as part of the crisis constellation. The episodic hypertension is thought to be caused by central release of catecholamines and exaggerated peripheral responses due to denervation hypersensitivity, as supersensitivity to cholinergic and adrenergic agents has been demonstrated [29, 30]. Hypertension is also more apt to occur when the patient is supine and again this may be due to exaggerated responses due to denervation hypersensitivity as the norepinephrine levels are not extraordinarily high in this position. Further manifestations of vasomotor and cardiovascular perturbations include erythematous skin blotching and hyperhydrosis with excitation or even eating.

The sensory abnormalities in individuals with FD are not as profound as with the other HSAN disorders and self-mutilation is rare. Pain and temperature perception are decreased but not absent [21, 31]. While bone and skin pain are poorly perceived, sensitivity to visceral pain has been observed. There are appropriate responses to pleural effusions, esophageal irritation, and menstrual cramping. Corneal and tendon reflexes are hypoactive, and taste appreciation is diminished which is due to absence of lingual fungiform papillae. Later in the course of the illness, vibratory sensory loss and impaired coordination appear [21]. Somatic growth is poor and by 10 years of age, 85% of patients have scoliosis [32] (Figure 3).

Developmental milestones are commonly delayed as a result of infantile hypotonia and poorly graded movements. Although receptive language is usually normal, expressive speech is delayed and often is poorly articulated or nasal in quality. Performance on standardized intelligence tests frequently demonstrates better verbal than motor performance [33]. Executive planning and organizational skills tend to be poor. Seizures with decerebrate posturing can follow breathholding even in children with normal EEG findings.

There is pathological and clinical evidence that FD is associated with neurological progression. The question is whether this progression is inherent to the disorder or is secondary to some of the other problems such as cardiovascular lability. In older patients, central neuropathology has not been documented but Magnetic Resonance Imaging (MRI's) frequently show generalized atrophy including the cerebellum. This may contribute to worsening of the ataxic gait and greater balance problems requiring the use of walkers or wheelchairs in the older patients. In some FD adults changes have also been noted in mental processing that can range from poor concentration to phobias to the rare occurrence of actual dementia [34]. There is also progressive optic nerve atrophy that severely limits vision in the older patients [35].

It is possible that compromised cerebral perfusion may contribute to the neurological progression with age as other cardiovascular perturbations worsen with age such as more pronounced problems with postural hypotension and worsening supine hypertension, development of ischemic glomerulosclerosis [36] and cardiac arrhythmias [37]. Supporting this hypothesis are the observation by Hilz et al of decreased or inappropriate cerebral blood flow under various conditions including tilt as well as hypoxia and hypercapnia [26, 38, 39]. Thus some of the neurological progression might be avoided with better management of blood pressure lability.

Fertility in both males and females has been proven, and offspring of affected individuals have been normal [40]. Progressive diminution of renal function with age is a frequent observation [36, 41]. Moderate azotemia is an early sign. Creatinine clearance decreases, and many patients have subnormal renin excretion. Nephrosclerosis has been reported on autopsy [36]. Despite these multiple problems, with improved supportive and preventative measures about half of the patients now reach adulthood [35, 42].

Pathology

Familial dysautonomia was originally reported as "central autonomic dysfunction with absent lacrimation" [4], yet consistent neuropathological findings all have been restricted to the periphery [43] and the information derived suggests that familial dysautonomia results from incomplete development of the sensory and autonomic systems, as well as limited survival of sensory and autonomic neurons, with sympathetic development more widely affected than parasympathetic. Overall there are decreased numbers of unmyelinated and small myelinated neurons. The sural nerve is hypoplastic and contains markedly reduced populations of nonmyelinated and small myelinated fibers, and there is lesser depletion of largemyelinated axons [44, 45]. Neuron somas in the Gasserian and spinal ganglia are reduced to 50% of the normal number and neuron somas in cervical and thoracic sympathetic ganglia are reduced to 27%–37% [43, 46]. The reduced size of cervical and thoracic ganglia is consistent with cardiac autonomic dysfunction. Sympathetic terminals are sparse or absent on vessels of skin, which probably contributes to vasomotor lability [47, 48]. Increasing residual nodules and decreasing neurons in older patients indicate a degenerative component. The dorsal columns conducting vibration, proprioceptive and touch information are initially normal but diminish markedly in older patients [46]. Parasympathetic ganglia are variably affected; the ciliary ganglion is normal or marginally depleted of neurons but the sphenopalatine ganglion has less than one tenth of that in the normal population. Consistent qualitative central nervous system (CNS) anomalies have not been found. However, there is increasing clinical evidence for central autonomic dysfunction and new genetic findings indicate that central regions have altered expression of the normal gene product [49]. Thus we assume that pathologic confirmation of central defects will eventually be provided.

Diagnosis

Diagnosis is based upon clinical recognition of both sensory and autonomic dysfunction. The combination of the "cardinal" criteria, i.e. alacrima, absent fungiform papillae (Figure 4), depressed patellar reflexes, and abnormal histamine test (Figure 1) in an individual of Ashkenazi Jewish extraction is usually sufficient to make the diagnosis.

As individuals affected with the other HSANs also fail to produce an axon flare after intradermal histamine [1], careful assessment of the other clinical signs and symptoms is necessary in order to distinguish between these disorders. Because there can be extreme variability in expression, clinical criteria are not always sufficient so that DNA molecular diagnostics should be performed to provide a definitive diagnosis. FD is the only HSAN for which commercially available genetic testing is available.

Management

Although gene identification holds the promise of eventually yielding more specific treatments for this disorder, at present treatments remain supportive and directed toward specific problems that vary considerably from patient to patient [50, 51]. In particular there are four areas that remain extremely problematic as they can severely limit independent function. These are alacrima, gastrointestinal dysfunction, respiratory dysfunction, and blood pressure lability. These problems continue to challenge the treating physician and provide the impetus to find definitive therapy for this disorder.

Clinical Presentation

HSAN IV is the second most common HSAN and like the other recessively transmitted HSAN onset is in infancy [1–3]. Several hundreds cases of HSAN IV have been published. What distinguishes HSAN IV is the extensive involvement of ectodermal structures including skin, bone and nervous system, especially absent or markedly decreased sweating, the cardinal feature of the disorder.

HSAN type IV is characterized by anhidrosis, absent or markedly decreased sweating [1–3, 12, 13, 55–58]. It is the anhidrosis that causes episodic fevers and extreme hyperpyrexia that is usually the earliest sign of the disorder and can cause recurrent febrile convulsions secondary to high environmental temperature [1, 12]. The anhidrosis is probably secondary to impaired thoracolumbar sympathetic outflow. It is present on the trunk and upper extremities in 100% of cases, whereas other areas of the body are variably affected. It causes the skin to become thick and callused with lichenification of palms, dystrophic nails, and areas of hypotrichosis on the scalp [12, 13, 56, 57].

Like FD, HSAN IV is associated with decreased sensation and autonomic dysfunction. It may be confused with FD in the neonatal period but the differences become much clearer with time as the characteristic anhidrosis causes cutaneous changes and the sensory insensitivity is much more profound resulting in self-mutilation, auto-amputation, and corneal scarring [1, 3, 12, 56, 57]. Although there is no immunological problem, individuals with HSAN IV have definite problems in healing of ectodermal structures – skin and bone. Fractures are slow to heal and large weight bearing joints appear particularly susceptible to repeated trauma and frequently go on to the development of Charcot joints and osteomyelitis (Figure 5). Speech is usually clear. Although hypotonia and delayed developmental milestones are frequent in the early years, strength and tone normalize with age. However, there can be severe learning problems. Hyperactivity and emotional lability are common [1, 3, 12, 56].

Other than the characteristic anhidrosis, other autonomic perturbations are mild to absent. Although patients exhibit myosis with dilute intraocular mecholyl, emotional tearing is normal [1, 3]. Postural hypotension with compensatory tachycardia may be present but not episodic hypertension suggesting that the blood pressure problems are secondary to disuse atrophy rather than sympathetic dysfunction. There is none to minimal gastrointestinal dysmotility; vomiting is not a feature of the disease and cyclical crises do not occur. Insensitivity to hypoxia and hypercapnia has not been noted. However, patients may have a heightened sympathetic response, as erythematous blotching of the skin with excitement has been seen in younger patients. Acrocyanosis is notably lacking. Gastrointestinal dysmotility is infrequent; vomiting is not a feature of the disease and cyclical crises do not occur [1, 3]. Insensitivity to hypoxia and hypercapnia has not been noted.

Pathology

Neuropathological studies have demonstrated decreased neuronal populations. Sural nerve biopsies show myelinated nerve fibers are present but unmyelinated fibers are absent [2]. Skin biopsy morphology of HSAN IV patients reveals deficient C and Aδ fibers in the epidermis and absent or hypoplastic dermal sweat glands without innervation [59–62].

Although sweat glands can be demonstrated in skin biopsies, unmyelinated fibers are not adjacent to sweat glands [2, 59–62]. The lack of sweat gland innervation accounts for the clinical manifestation of severe anhidrosis and the objective absence of sympathetic skin responses (SSR) [63]. Although central neuropathology has not been demonstrated for HSAN type IV, affected individuals have clinical features suggesting central involvement as the patients are frequently exhibit hypotonia and delayed developmental milestones in the early years and there can be severe learning problems, often associated with hyperactivity [1, 12, 58].

Diagnosis

It has been suggested that diagnosis of this disorder requires three clinical criteria, i.e. anhidrosis, decreased pain perception and mental retardation [12]. However, our experience indicates that the degree of expression of the three clinical features, especially intellectual ability, can be extremely varied. In addition to the absence of an axon flare following intradermal histamine, which is common to all the HSAN, clinical diagnosis is primarily based on the fact that HSAN IV is the only HSAN that is associated with widespread anhidrosis. The sensory abnormalities are also profound and widespread. They include cranial nerves and visceral sensation resulting in insensitivity to superficial as well as deep, visceral painful stimuli and in impressive self-mutilation and traumatized joints. Temperature sensation is also decreased or absent but deep tendon reflexes are usually intact. Although there has been gene identification, numerous mutations does not allow simple DNA diagnosis so that it is not routinely used for clinical confirmation of diagnosis [12, 13]. Penetrance is complete, but expression varies widely and may be related to the site of the mutation on the NGF receptor or whether there is genetic homo- or heterozygosity [55].

Management

Medical management is supportive and oriented to control of hyperthermia, prevention of self-mutilation and treatment of orthopedic problems that potentially can cause severe and debilitating deformities. In addition it is also necessary to help families cope with behavior and educational issues. Febrile spikes will respond to use of acetaminophen and/or ibuprofen or direct cooling in a bath or cooling blanket. Diazepam, which is used for FD patients, has not been as effective in CIPA patients; chlorpromazine or chloral hydrate is more effective in relaxing the children and allowing them to cool. Careful daily inspection for unrecognized injury is important. Braces may be required on the ankles to prevent injury to these weight bearing joints. Some children will require smoothing of the teeth or extraction to prevent self-mutilation of the tongue and lips. Irritability, hyperactivity, and susceptibility to rages are seen in about 50% of patients. Chlorpromazine has been helpful as well as behavior modification. The prognosis for independent function depends on the degree of disease expression and the ability to control the secondary clinical problems.