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Painful sweating

From Clinical Neurocardiology Section (Drs. Goldstein and Eldadah, and S. Pechnik), National Institute of Neurological Disorders and Stroke, Bethesda, MD; and Children’s National Medical Center (Dr. Moak), Washington, DC.

Address correspondence and reprint requests to Dr. David S. Goldstein, National Institute of Neurologic Disorders and Stroke, Clinical Neurocardiology Section, Building 10, Room 6N252, 10 Center Drive, MSC 1620, Bethesda, MD 20892-1620; e-mail: goldsteind{at}ninds.nih.gov

Objective: The authors report a case of spontaneous and gustatory facial pain and sweating.

Methods: The patient had frequent episodes of pain, sweating, and flushing bilaterally in the hairless skin of the ophthalmic and maxillary distributions of the trigeminal nerve. Gustatory stimuli (e.g., orange juice, pickled onions) reliably evoked episodes, but episodes also frequently came on spontaneously. The problem had begun during adolescence, about the time of topical treatment and then electrocauteries for facial warts. The patient reported benefit from tricyclic antidepressants, guanethidine, and trospium chloride (an anti-cholinergic quaternary amine used in Europe for urinary urgency). There was no pain or excessive sweating in other body areas, nor pain with exercise.

Results: Administration of edrophonium IV evoked pain and sweating, and ganglion blockade by IV trimethaphan eliminated pain and sweating and markedly attenuated responses to edrophonium. Trospium chloride also prevented edrophonium-induced pain and sweating. Bicycle exercise produced the same increment in forehead humidity as in a spontaneous episode but did not evoke pain. Tyramine infusion did not bring on pain or sweating, whereas iontophoretic acetylcholine administration to one cheek evoked pain and sweating bilaterally. Topical glycopyrrolate cream eliminated spontaneous, gustatory, and edrophonium-induced episodes.

Conclusions: The findings indicate that facial pain and sweating can result from occupation of muscarinic cholinergic receptors after acetylcholine release from local nerves. The authors propose that after destruction of cutaneous nerves, aberrant regenerant sprouting innervates sweat glands, producing gustatory sweating as in auriculotemporal syndrome (Frey syndrome), and innervates nociceptors, producing pain.

Received March 23, 2004. Accepted in final form June 8, 2004.