Unilateral anhidrosis First clinical manifestation of bronchial carcinoma

European Journal of Dermatology. Volume 11, Number 3, 257-8, May - June 2001, Votre diagnostic !

Author(s) : M.A. Muñoz-Pérez, J. Mazuecos, M. Ortega F. Camacho, Department of Dermatology, Hospital Virgen Macarena, Avda Dr. Fedriani s/n, Sevilla 41009, Spain..

Summary : A 69-year-old white man presented with a 6 month history of pain and paresthesia on his left shoulder that slowly extended to the left pectoral area, and absence of sweating over the left upper half of his body. He also complained of hyperhidrosis of the right side of the body. Results of sweat testing using one-step iodine-starch method demonstrated left-sided anhidrosis affecting the face, upper limb, and chest (Fig. 1). Results of neurological examination demonstrated no sensory, thermic nor pain deficit. Superficial and deep reflexes were normal. He has no associated ptosis or miosis. Pilocarpina 0.1 mL of 1/1,000 solution was injected subcutaneously on the volar surface of both forearms after iodine and starch powder was applied, and sweat was only noted at the injection site in the right arm, with absence of sweating in the left arm. Examination of a skin biopsy specimen from the left upper back revealed poorly developed eccrine glands. A thoracic X-ray showed a deviation of the trachea (Fig. 2) and a computed axial tomographic (CT) scan also revealed a solid mass next to the apical left and posterior pleura (Fig. 3).

ARTICLE

A 69-year-old white man presented with a 6 month history of pain and paresthesia on his left shoulder that slowly extended to the left pectoral area, and absence of sweating over the left upper half of his body. He also complained of hyperhidrosis of the right side of the body. Results of sweat testing using one-step iodine-starch method demonstrated left-sided anhidrosis affecting the face, upper limb, and chest (Fig. 1). Results of neurological examination demonstrated no sensory, thermic nor pain deficit. Superficial and deep reflexes were normal. He has no associated ptosis or miosis. Pilocarpina 0.1 mL of 1/1,000 solution was injected subcutaneously on the volar surface of both forearms after iodine and starch powder was applied, and sweat was only noted at the injection site in the right arm, with absence of sweating in the left arm. Examination of a skin biopsy specimen from the left upper back revealed poorly developed eccrine glands. A thoracic X-ray showed a deviation of the trachea (Fig. 2) and a computed axial tomographic (CT) scan also revealed a solid mass next to the apical left and posterior pleura (Fig. 3).

Unilateral anhidrosis First clinical manifestation of bronchial carcinoma

Comments

Anhidrosis and hyperhidrosis can be neurological manifestations of processes affecting central or peripheral nervous system like tumors, infarcts, injuries or hemorrhages of the brain and/or the medulla. We describe a elderly white man with left side anhidrosis, and a compensating hyperhidrosis of the right side, due to a paravertebral infiltration of a bronchial tumor that histologically was a not oat cell carcinoma.

The eccrine sweat glands are innervated by the sympathetic nervous system. Fibers originating in the cerebral cortex traverse the hypothalamus, then cross in the medulla to the lateral horn of the spinal cord. These fibers leave the spinal cord to synapse in the sympathetic ganglia with neurons that innervate the sweat glands [1]. Thus, a cortical lesion will cause contralateral anhidrosis, a lesion in the medulla could result in contralateral or ipsilateral anhidrosis, and any lesion distal to the medulla will cause ipsilateral anhidrosis. Unilateral hyperhidrosis has been reported in association with malignant mesothelioma [2] and bronchial carcinoma [3]. Unilateral localized hyperhidrosis can also be idiopathic [4], or can be secondary to an eccrine naevus [5]. Some patients may have areas of hyperhidrosis, which creates an impression that the rest of the body is anhidrotic. On the other hand, patients will complain of hyperhidrosis when in reality this is due to a localized overproduction of sweat on normal skin to compensate for an area of hypohidrosis.

Stellate ganglion syndrome is due to interruption of the sympathetic fibers at any point along the internal carotid arteries or the stellate (cervicothoracic) ganglion, and includes miosis, drooping of the eyelid, apparent enophthalmos, and abolition of sweating over one side of the face and upper trunk. When a bronchial carcinoma is the cause, this syndrome is called "Pancoast's tumor" [6] or "Pancoast's syndrome" [7]. In our case, the neoplastic mass did compress or invade the stellate ganglion and anhidrosis was the first symptom of the malignancy. Unilateral anhidrosis has been reported in a patient who suffered a heat stroke [8], and also in patient with a lesion in the hypothalamus [9].

In conclusion, it is important to think about a neoplasm in the diagnosis outline of unilateral anhidrosis, because it can be the first clinical symptom of that malignancy.

References

1. Sato K, Kong WH, Saga K. Biology of sweat glands and their disorders. I. Normal sweat gland function. J Am Acad Dermatol 1989; 20: 537-63.

2. Pleet DL, Mandel S, Neilan B. Paroxysmal unilateral hyperhidrosis and malignant mesothelioma. Arch Neurol 1983; 40: 256.

3. Middleton WG. Bronchial carcinoma with pleural spread causing unilateral thoracic hyperhidrosis. Br Med J 1976; 2: 563.

4. Boyvat A, Piskin G, Hatice E. Idiopathic unilateral localized hyperhidrosis. Acta Derm Venereol (Stockh) 1999; 79: 404-5.

5. Ruiz de Erenchum F, Vazquez Doval FJ, Contreras Mejuto F, Quintanilla E. Localized unilateral hyperhidrosis: eccrine nevus. J Am Acad Dermatol 1992; 27: 115-6.

6. Derbekyan V, Novales-Diaz J, Lisbona R. Pancoast tumor as a cause of reflex sympathetic dystrophy. J Nucl Med 1993; 34: 1992-4.

7. Arcasoy SM, Jett JR. Superior pulmonary sulcus tumors and Pancoast's syndrome. N Engl J Med 1997; 6: 1370-6.

8. Chakravarti DN, Jyasi N. A case of hemi-anhidrosis. J R Army Med Corps 1946; 24: 336-7.

9. Brazis PW, Masden JC, Biller J. Localization. In: Clinical neurology. Boston, Little Brown, 1990: 308.


		Figure 1. Sweat test using iodine-starch method, demonstrating anhidrosis affecting the left face, left chest, and left arm.


		Figure 2. Thoracic X-ray : trachea deviation.


		Figure 3. Computed axial tomographic scan revealing a solid mass next to the apical posterior pleura.