Autonomic Dysregulation

 Autonomic dysfunction, taken as a whole, is not infrequent. The most common autonomic dysfunction occurs in the cardiovascular control sphere and consists of an abnormal vasovagal response that leads to syncope. Other common manifestations are related to Postural Tachycardia Syndrome (POTS), or changes seen with Parkinson disease and other Parkinsonism’s. Urinary incontinence, related to other areas of autonomic control, as observed in multiple sclerosis and other nervous system disorders, is unspecific but not rare. There are symptoms of autonomic disturbance in some situations where they are second in importance but help in diagnosis, for example, the facial vasomotor and ocular symptoms in trigeminal autonomic headaches. A detailed history of symptoms in each area should guide us to a list of possible diseases with autonomic dysfunction. Place special emphasis on cardiovascular, urinary, and sudomotor symptoms, together with accompanying neurologic and non-neurologic manifestations, along with a thorough examination. A key feature of autonomic dysfunction, either orthostatic syncope or presyncope should guide us to a suspicion of cardiovascular autonomic dysfunction, the latter with dizziness, giddiness, blurred or tunnel vision, headache or neckache (coat-hanger pain), nausea, or fatigue. Vesical ultrasonography and urodynamic studies help figure out what the problem looks like and what the best pharmacologic approach is for urinary dysfunction. Other tests are not as useful in changing the management but may play a role in support of an explanation for the patient’s symptoms, or as adjunctive for syndromic diagnosis, as it is the case with blocking eyedrop tests and pupillometry for pupillary abnormalities. On the other hand, positive testing results for autoantibodies, for example, antibodies against alfa-3-acetylcholine receptor, help support immunosuppressive therapy.