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Iatrogenic harlequin syndrome

Hillingdon Vascular Unit, Hillingdon Hospital, Pield Heath Road, Uxbridge, Middlesex UB8 3NN, UK; marios@nicolaou.org

The first 100% of the full text of this article appears below.

Thoracoscopic sympathectomy is a safe, effective, minimally invasive treatment for primary hyperhidrosis.¹

A 29 year old man with severe facial hyperhidrosis underwent an uncomplicated right thoracoscopic sympathectomy. Before operating on his left side, a starch-iodine preparation was applied to his face in order to demarcate residual sudomotor function. The preparation becomes blue on exposure to moisture, thereby representing residual sweat gland activity.

Figure 1 demonstrates that sympathetic innervation to the face is strictly unilateral, and nerve fibres do not appear to cross the midline. This is essentially an iatrogenic variation of the harlequin syndrome,² which usually results from interruption of post-ganglionic sympathetic fibres secondary to malignant invasion.

View larger version (95K): [in this window] [in a new window]   Figure 1 Starch-iodine preparation applied to patient’s face (published with patient’s permission).

1. Lin TS, Fang HY. Transthoracic endoscopic sympathectomy in the treatment of palmar hyperhidrosis—with emphasis on perioperative management (1,360 case analyses). Surg Neurol 1999;52:453–7.[CrossRef][Medline]
2. Montigiani A, Cencetti S, Bandinelli G, et al. The "harlequin sign". Case description and review of the literature. Ann Ital Med Int 1998;13:173–5.[Medline]