title: Absence of pain with hyperhidrosis: a new syndrome where vascular afferents may mediate cutaneous sensation.
abstract: Congenital absence of pain perception is a rare phenotype. Here we report two unrelated adult individuals who have a previously unreported neuropathy consisting of congenital absence of pain with hyperhidrosis (CAPH). Both subjects had normal intelligence and productive lives despite failure to experience pain due to broken bones, severe cold or burns. Functional assessments revealed that both are generally hypesthetic with thresholds greater than two standard deviations above normal for a several of modalities in addition to noxious stimuli. Sweating was 3 to 8-fold greater than normal. Sural nerve biopsy showed that all types of myelinated and unmyelinated fibers were severely reduced. Extensive multi-antibody immunofluorescence analyses were conducted on several skin biopsies from the hands and back of one CAPH subject and two normal subjects. The CAPH subject had all normal types of immunochemically and morphologically distinct sensory and autonomic innervation to the vasculature and sweat glands, including a previously unknown cholinergic arterial innervation. Virtually all other types of normal cutaneous C, Adelta and Abeta-fiber endings were absent. This subject had no mutations in the genes SCN9A, SCN10A, SCN11A, NGFB, TRKA, NRTN and GFRA2. Our findings suggest three hypotheses: (1) that development or maintenance of sensory innervation to cutaneous vasculature and sweat glands may be under separate genetic control from that of all other cutaneous sensory innervation, (2) the latter innervation is preferentially vulnerable to some environmental factor, and (3) vascular and sweat gland afferents may contribute to conscious cutaneous perception.
authors.affiliation: Pain Research Institute, Liverpool, UK.
authors.forename: David
authors.initials: D
authors.lastname: Bowsher
authors.forename: C
authors.initials: C
authors.lastname: Geoffrey Woods
authors.forename: Adeline K
authors.initials: AK
authors.lastname: Nicholas
authors.forename: Ofelia M
authors.initials: OM
authors.lastname: Carvalho
authors.forename: Carol E
authors.initials: CE
authors.lastname: Haggett
authors.forename: Brian
authors.initials: B
authors.lastname: Tedman
authors.forename: James M
authors.initials: JM
authors.lastname: Mackenzie
authors.forename: Daniel
authors.initials: D
authors.lastname: Crooks
authors.forename: Nasir
authors.initials: N
authors.lastname: Mahmood
authors.forename: J Aidan
authors.initials: JA
authors.lastname: Twomey
authors.forename: Samantha
authors.initials: S
authors.lastname: Hann
authors.forename: Dilwyn
authors.initials: D
authors.lastname: Jones
authors.forename: James P
authors.initials: JP
authors.lastname: Wymer
authors.forename: Phillip J
authors.initials: PJ
authors.lastname: Albrecht
authors.forename: Charles E
authors.initials: CE
authors.lastname: Argoff
authors.forename: Frank L
authors.initials: FL
authors.lastname: Rice
mesh_terms: D000328:Adult; D000369:Aged, 80 and over; D001341:Autonomic Nervous System / Q000503:physiopathology; D006801:Humans; D006945:Hyperhidrosis / Q000150:complications* / Q000235:genetics / Q000473:pathology*; D008297:Male; D009412:Nerve Fibers / Q000378:metabolism / Q000473:pathology; D016900:Neurofilament Proteins / Q000378:metabolism; D009479:Neuropeptides / Q000378:metabolism; D009842:Oligopeptides / Q000378:metabolism; D000699:Pain Insensitivity, Congenital / Q000150:complications* / Q000235:genetics / Q000473:pathology*; D017288:Pain Threshold / Q000502:physiology; D011392:Proline / Q000031:analogs & derivatives / Q000378:metabolism; D012720:Severity of Illness Index; D012867:Skin / Q000294:innervation* / Q000503:physiopathology*; D050494:Vesicular Acetylcholine Transport Proteins / Q000378:metabolism
chemical_list: D016900:Neurofilament Proteins; D009479:Neuropeptides; D009842:Oligopeptides; C493459:SLC18A3 protein, human; D050494:Vesicular Acetylcholine Transport Proteins; C113164:prolyl-glycyl-proline; D011392:Proline