Peripheral autonomic failure: symptoms

Symptoms of peripheral vegetative insufficiency are presented in all physiological systems of the body and can occur under the mask of many somatic diseases. Typical clinical syndromes are the following:

1. Orthostatic hypotension.
2. Tachycardia at rest.
3. Hypertension in prone position.
4. Hypodidrosis.
5. Impotence.
6. Gastroparesis.
7. Constipation.
8. Diarrhea.
9. Urinary incontinence.
10. Decreased vision at dusk.
11. Apnea in a dream.

These syndromes are given in the sequence that corresponds to the prevailing frequency of occurrence. However, in each case of peripheral autonomic failure, the "set" of symptoms may be different and not always complete (11 signs). So, for primary forms of peripheral vegetative insufficiency, such manifestations as orthostatic hypotension, tachycardia at rest, hypohydrosis, impotence are more characteristic. With secondary syndromes of peripheral vegetative insufficiency, sweating disorders predominate in some cases (with alcoholism, polyneuropathy), in others - tachycardia at rest (with diabetes mellitus) or gastrointestinal disorders (amyloidosis, porphyria), etc. It is not surprising that patients with signs of vegetative failure are addressed to specialists of different profiles - cardiologists, neuropathologists, gynecologists, sexopathologists, geriatricians, etc.

The most dramatic manifestation of peripheral autonomic failure in the cardio-vascular system is orthostatic hypotension, leading to frequent faints when going to a vertical position or standing for a long time. Orthostatic hypotension is a condition that occurs in a variety of diseases (neurogenic syncope, anemia, varicose veins, heart pathology, etc.). It should be noted, however, that in peripheral autonomic failure, orthostatic hypotension is caused by damage to the lateral horns of the spinal cord and / or efferent sympathetic vasomotor conductors that realize vasoconstrictor effects on peripheral and visceral vessels. Therefore, with orthostatic loads, there is no peripheral vasoconstriction, which leads to a drop in systemic blood pressure, and then, respectively, to acute brain anoxia and fainting.

Patients may have different severity of clinical manifestations. In mild cases, soon after taking a vertical position (rising), the patient begins to observe signs of a pre-fainting condition (lipotymia), manifested by a sensation of faintness, dizziness, a premonition of loss of consciousness. The patient, as a rule, complains of general weakness, darkening of the eyes, tinnitus and head, unpleasant sensations in the epigastric region, sometimes a feeling of "failure", "floating of the soil from under the feet", etc. Pale skin integument, short-term postural instability. The duration of lipotomy 3-4 seconds. In more severe cases, fainting may develop following lipotomy. The duration of syncope in peripheral vegetative failure is 8-10 s, sometimes (with the syndrome Shy - Drager) - several tens of seconds. During fainting, diffuse muscular hypotension, dilatation of the pupils, retraction of the eyeballs upwards, filiform pulse, low blood pressure (60-50 / 40-30 mm Hg and below) are noted. With a syncope lasting more than 10 s, there may be seizures, hypersalivation, urinary leakage, in very rare cases, a bite of the tongue may occur. Coarse orthostatic circulatory disorders can lead to death. Fainting states in peripheral vegetative insufficiency differ from other faints by the presence of hypo- and anhidrosis and the absence of a vagal PC slowing reaction. In order to assess the severity of orthostatic disorders, in addition to taking into account clinical manifestations, it is convenient to use the rate of onset of syncope after taking the vertical position of the body. The interval of time from the moment of transition of the patient from a horizontal position to a vertical position until the fainting of a brawnlet is reduced to several minutes or even up to 1 minute or less. This indicator is always adequately indicated by the patient and quite accurately characterizes the severity of orthostatic circulatory disturbances. In dynamics, it also reflects the rate of progression of the disease. In severe cases, fainting can develop even when sitting.

Orthostatic hypotension is the main sign of primary peripheral autonomic failure. Secondarily, it can be observed in diabetes, alcoholism, Guillain-Barre syndrome, chronic kidney failure, amyloidosis, porphyria, bronchial carcinoma, leprosy and other diseases.

Along with orthostatic hypotension, peripheral vegetative insufficiency often develops such a phenomenon as hypertension in prone position. As a rule, in these cases, with prolonged lying during the day or during a night's sleep, the blood pressure rises to high figures (180-220 / 100-120 mm Hg). These shifts in arterial pressure are due to the so-called post-provender hypersensitivity of the adrenoreceptors of smooth muscle vessels, which inevitably forms in chronic denervation processes (the law of post-provender hypersensitivity of Canon). Taking into account the possibility of the appearance of arterial hypertension in patients with peripheral vegetative insufficiency, suffering from orthostatic hypotension, is extremely important in the appointment of drugs that increase blood pressure. As a rule, drugs with powerful direct vasoconstrictive action (norepinephrine) are not prescribed.

Another bright sign of peripheral autonomic failure is tachycardia at rest (90-100 beats / min). Because of the reduced variability of the heart rhythm, this phenomenon was called the "fixed pulse". In a patient with peripheral vegetative insufficiency, various loads (rising, walking, etc.) are not accompanied by an adequate change in heart rate, with a clear trend towards tachycardia at rest. It is proved that tachycardia and reduced variability in this case is due to parasympathetic insufficiency due to the defeat of efferent vagal cardial branches. The defeat of the afferent visceral nerves, coming from the cardiac muscle, leads to the fact that myocardial infarction can proceed without pain. For example, in patients with diabetes every third myocardial infarction proceeds without pain. It is painless myocardial infarction is one of the causes of sudden death in diabetes mellitus.

One of the characteristic manifestations of peripheral vegetative insufficiency is hypo- or anhidrosis. Reduced sweating on the limbs and trunk with peripheral vegetative failure is the result of the defeat of efferent shipmaking sympathetic devices (lateral horns of the spinal cord, vegetative ganglia of the sympathetic chain, pre- and post-tangionic sympathetic fibers). The prevalence of sweating disorders (diffuse, distal, asymmetric, etc.) is determined by the mechanisms underlying the disease. As a rule, patients do not pay attention to reduced sweating, so the doctor should himself clarify and assess the state of sweating. The detection of hypohidrosis along with orthostatic hypotension, tachycardia at rest, gastrointestinal disorders, urinary disturbance makes the diagnosis of peripheral vegetative insufficiency more likely.

Peripheral vegetative insufficiency in the gastrointestinal system is caused by the defeat of both sympathetic and parasympathetic fibers, manifested by a violation of the motility of the gastrointestinal tract and the secretion of gastrointestinal hormones. Gastrointestinal symptoms are often nonspecific and unstable. Symptomocomplex gastroparesis includes nausea, vomiting, a feeling of "overcrowded" stomach after eating, anorexia and is caused by damage to the gastric motor branches of the vagus nerve. It should be emphasized that constipation and diarrhea in peripheral vegetative insufficiency are not associated with the alimentary factor, and their severity depends on the degree of disturbance of parasympathetic and sympathetic innervation of the intestine, respectively. These disorders can be observed in the form of attacks from several hours to several days. Between attacks, the bowel function is normal. For correct diagnosis, you must exclude all other causes of gastroparesis, constipation and diarrhea.

Violation of bladder function in peripheral autonomic failure is due to the involvement of the parasympathetic innervation of the detrusor and sympathetic fibers that go to the internal sphincter in the pathological process. Most often, these disorders are manifested by the picture of atony of the bladder: straining with urination, large interruptions between acts of urination, urination from the overflowing bladder, feeling of incomplete emptying, attachment of secondary uroinfection. Differential diagnosis should include adenoma and prostatic hypertrophy, other obstructive processes in the genitourinary sphere.

One of the symptoms of peripheral vegetative insufficiency is impotence, caused in such cases by parasympathetic nerves lesions of cavernous and spongy bodies. In primary forms, impotence occurs up to 90% of cases, with diabetes - in 50% of patients. The most urgent task is to distinguish between psychogenic impotence and impotence in peripheral vegetative insufficiency. It is important to pay attention to the features of the debut of impotence (psychogenic forms come suddenly, organic (peripheral vegetative insufficiency) - gradually) and the presence of erections during night sleep. The preservation of the latter confirms the psychogenic nature of the disorder.

Peripheral vegetative insufficiency can be manifested by disturbances in the respiratory system. These include, for example, short-term stops of breathing and cardiac activity in diabetes mellitus (the so-called "cardiorespiratory arrest"). They usually occur during general anesthesia and in severe bronchopneumonia. Another frequent clinical phenomenon in patients with peripheral vegetative insufficiency (Shy-Drager syndrome, diabetes mellitus) are episodes of sleep apnea, which can sometimes take a dramatic character; less often, spontaneous attacks of suffocation (stridor, "cluster" breathing) are described. These ventilation disorders become dangerous in violation of cardiovascular reflexes, and suggest that they may be the cause of sudden unexplained death, in particular, in diabetes mellitus.

Visual impairment in the twilight with peripheral vegetative failure is associated with impaired innervation of the pupil, which leads to its insufficient expansion in conditions of poor illumination and, accordingly, disturbs the visual perception. Such a violation should be distinguished from the condition that occurs with vitamin A deficiency. Other symptoms of peripheral vegetative insufficiency or hypovitaminosis A manifestations may be auxiliary. Usually pupillary disorders in peripheral vegetative insufficiency do not reach the expressed degree and are not noticed by patients for a long time.

Thus, it should be emphasized that the clinical manifestations of peripheral vegetative insufficiency are polysystemic and often nonspecific. It is certain clinical nuances described above that suggest the patient has peripheral vegetative failure. To clarify the diagnosis, it is necessary to exclude all other possible causes of existing clinical symptoms, for which additional methods of investigation can be used.

[1], [2], [3], [4], [5], [6], [7], [8]