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A Guide To Sudoscan New
A Guide To Sudoscan New
A Guide To Sudoscan New
Eccrine
sweat
glands
are
innervated
by
long,
thinly
myelinated
and
unmyelinated
C
fibers
of
the
sympathetic
nervous
system
that
are
prone
to
early
damage
in
many
neuropathic
processes,
including
dysautonomia.
Small
fiber
neuropathy
(SFN)
may
be
the
first
manifestation
of
systemic
disease
and
can
predict
progression
to
a
more
diffuse
neuropathy,
making
this
early
diagnosis
important
for
the
treatment
of
patients.
SUDOSCAN
results
will
enable
you
to
perform
an
objective
assessment
of
small
and
peripheral
sympathetic
nerve
fiber
function.
This
will
help
you
to
identify
the
etiology
of
the
disease,
keeping
in
mind
that
about
33%
of
small
fiber
neuropathies
remain
idiopathic
despite
appropriate
diagnostic
evaluation.
Objective
evaluation
of
the
disease
with
regular
interval
retesting
can
increase
patient
compliance
and
can
be
particularly
important
in
the
treatment
of
neuropathic
pain,
if
present.
The
results
of
SUDOSCAN
tests
are
provided
as
hand
and
foot
Electrochemical
Skin
Conductances
(ESC)
that
indicate
sweat
dysfunction
and
are
a
marker
of
small
fiber
peripheral
neuropathy.
ESC
are
expressed
in
microSiemens
(μS),
ranging
from
0
to
100.
In
general,
ESC
in
the
‘green’
zone
are
healthy,
ESC
in
the
‘yellow’
zone
indicate
moderate
dysfunction,
and
ESC
in
the
‘orange-‐red’
zone
correspond
to
severe
dysfunction.
The
two
main
points
to
consider
for
correct
interpretation
of
SUDOSCAN
results
are:
§ Asymmetry.
If
greater
than
20%
it
suggests
damage
limited
to
a
single
side.
This
is
only
valid
when
the
contralateral
ESC
scores
are
in
the
‘green’
zone.
If
the
contralateral
ESC
is
itself
in
the
‘yellow’
or
‘red’
zone,
then
bilateral
dysfunction
exists.
§ Location
of
disturbances
(hands
or
feet)
to
evaluate
length
dependency
of
the
damage.
In
the
diagnostic
strategy
the
following
questions
should
also
be
answered:
§ What:
Are
there
other
signs
or
symptoms
of
autonomic
dysfunction?
Are
sensory
or
motor
nerves
(large
fibers)
involved?
§ When:
If
symptoms
are
present,
how
long
have
they
been
present
and
was
their
onset
acute
or
chronic?
§ Context:
What
are
the
patient’s
medical
history,
current
or
past
medications,
family
history
(hereditary
diseases)?
Peripheral
and
cardiac
autonomic
neuropathy
Heart
rate
variability,
Ewing
tests,
appropriate
specialist
5
referral
Familial
Amyloid
Polyneuropathy
Medical
and
family
history,
genetic
testing,
appropriate
6
specialist
referral
*classified according to frequency of occurrence; potential causes are not mutually exclusive
Chronic alcohol abuse, history of alcoholism Medical history, clinical examination, liver function tests
Pharmacological
toxins
(statins,
anti-‐ Medical
history
including
current
and/or
past
medications
retrovirals),
chemotherapy
Environmental
Toxins,
Infections
(HIV,
Toxin
exposure
history,
specialized
toxicological
and
infectious
8-‐10
Hepatitis
C,
Lyme
disease)
disease
studies
Hypothyroidism Medical history, clinical examination, TSH and free T4 levels
Potential
unverified
causes
of
asymmetry
in
Suggested
evaluation
SUDOSCAN
results
Nerve
entrapment:
spinal
or
peripheral
Medical
history,
physical
and
neurological
examination,
(carpal
tunnel,
tarsal
tunnel)
unilateral
extremity
weakness
Peripheral Artery Disease (PAD) Ankle brachial index, arterial Duplex ultrasound, angiography
Dorsal
root
ganglion,
sympathetic
ganglion
Neurological
examination,
appropriate
referral,
imaging
study
chain
disease
Complex Regional Sympathetic Dystrophy Medical history, physical examination, imaging study
Effect
on
SUDOSCAN
Potential
confounding
factors
to
Examples
and
Comments
SUDOSCAN
results,
not
fully
validated
by
research
REFERENCES
[1]
Schwarz
P,
Brunswick
P,
Calvet
JH.
EZSCAN
a
new
tool
to
detect
diabetes
risk.
British
Journal
of
Diabetes
&
Vascular
diseases.
2011;11(4):204-‐9.
[2]
Casellini
CM,
Parson
HK,
Richardson
MS,
Nevoret
ML,
Vinik
AI.
Sudoscan,
a
Noninvasive
Tool
for
Detecting
Diabetic
Small
Fiber
Neuropathy
and
Autonomic
Dysfunction.
Diabetes
Technol
Ther.
2013;15(11).
[3]
Ozaki
R,
Cheung
KK,
Wu
E,
Kong
A,
Yang
X,
Lau
E,
Brunswick
P,
Calvet
JH,
Deslypere
JP,
Chan
JCN.
A
new
tool
to
detect
kidney
disease
in
Chinese
type
2
diabetes
patients—comparison
of
EZSCAN
with
standard
screening
methods.
Diabetes
tech
&
ther.
2011;13(9):937-‐43.
[4]
Freedman
BI,
Bowden
DW,
Smith
SC,
Xu
J,
Divers,
J.
Relationships
between
electrochemical
skin
conductance
and
kidney
disease
in
type
2
diabetes.
In
Press.
[5]
Yajnik
CS,
Kantikar
V,
Pande
A,
Deslypere
JP,
Dupin
J,
Calvet
JH,
Bauduceau
B.
Screening
of
cardiovascular
autonomic
neuropathy
in
patients
with
diabetes
using
non-‐invasive
quick
and
simple
assessment
of
sudomotor
function.
Diabetes
Metab.
2013
Apr;39(2):126-‐31.
[6]
Adams
D,
Cauquil
C,
Mincheva
Z,
Theaudin
M,
Beaudonnet
G,
Labeyrie
C,
Depuydt
S,
Iliescu
I,
Lacroix
C,
Grisoni
ML.
Sudomotor
function
assessment
by
SUDOSCAN
in
FAP
patients:
the
NNERF
experience.
Poster
presentation.
Peripheral
Nerve
Society.
Saint-‐Malo,
France,
June
2013.
[8]
Burns
TM,
Mauermann
ML.
The
evaluation
of
polyneuropathies.
Neurology.
2011
Feb
15;76(7
Suppl
2):S6-‐13.
[9]
Freeman
R.
Autonomic
peripheral
neuropathy.
Lancet
2005;365:1259-‐1270.
[10]
Tavee
J,
Zhou
L.
Small
fiber
neuropathy:
a
burning
problem.
Cleve
Clin
J
Med.
2009
May;76(5):297-‐305.
[11]
Pharmacist’s
Letter/Prescriber’s
Letter
–
Document
#271206.
Therapeutic
Research
Center.
December
2011.
Available
at
www.pharmacistletter.com.
SUDOSCAN
report
> Feet
Mean
ESC:
26
μS,
10%
asymmetry
> Hands
Mean
ESC:
72
μS,
1%
asymmetry
Discussion
Results
are
suggestive
of
a
peripheral
autonomic
and
small
fiber
dysfunction.
From
the
brief
history,
the
most
likely
clinical
suspicion
should
be
dysglycemia,
whether
metabolic
syndrome,
impaired
glucose
tolerance,
or
diabetes.
An
appropriate
work-‐up
and
intervention
should
be
conducted;
SUDOSCAN
should
be
repeated
in
3
months
or
as
medically
necessary
after
treatment
is
instituted.
If
low
feet
scores
persist,
consider
screening
for
cardiac
autonomic
neuropathy
risk.
Effect
of
Case
2
alcohol
Background
55
year-‐old
Caucasian
male
with
past
medical
history
of
mild
hypertension,
BMI
29;
he
is
asymptomatic.
SUDOSCAN
report
At
t=0
> Feet
Mean
ESC:
38
μS,
19%
asymmetry
> Hands
Mean
ESC:
56
μS,
5%
asymmetry
After
48
hours
> Feet
Mean
ESC:
87
μS,
3%
asymmetry
> Hands
Mean
ESC:
88
μS,
0%
asymmetry
Discussion
The
patient
was
a
physician
attending
a
medical
conference
and
was
scanned
following
ingestion
of
a
large
amount
of
alcohol
earlier
in
the
day.
He
was
obviously
impaired
at
time
of
testing.
Alcohol
may
result
in
a
chronic
neuropathy,
but
may
also
impair
SUDOSCAN
scores
following
moderate
consumption.
Repeat
testing
after
48
hours
of
sobriety
showed
completely
normal
SUDOSCAN
results.
Effect
of
Case
3
medication
Background
55
year-‐old
female
treated
with
amitriptyline
for
depression
with
insomnia.
No
other
significant
past
medical
history.
SUDOSCAN
report
§ SUDOSCAN
score
while
on
amitriptyline
> Feet
ESC
8
μS,
Hands
ESC
22
μS
§ SUDOSCAN
report
24
hours
after
stopping
amitriptyline
>
Feet
ESC
38
μS
,
Hands
ESC
56
μS
§ SUDOSCAN
report
48
hours
after
stopping
amitiriptyline
> Feet
ESC
60
μS
,
Hands
ESC
46
μS
Discussion
Amitriptyline,
a
tricyclic
antidepressant,
has
significant
anti-‐cholinergic
effects.
This
is
most
likely
the
reason
for
this
patient’s
dramatically
low
ESC
scores,
considering
she
has
no
known
neuropathy
and
sympathetic
nerve
endings
on
sweat
glands
predominantly
release
acetylcholine
as
a
neurotransmitter.
ESC
scores
eventually
returned
to
normal
after
removal
of
amitryptiline.
Background
45
year-‐old
right-‐handed
African
American
female
with
tingling
and
numbness
in
her
right
hand.
Diagnosed
2
years
ago
with
Type
2
DM;
treated
with
Metformin
BID
with
HbA1c
stable
at
7.0%;
BMI
30.
She
is
employed
as
a
receptionist/administrative
assistant
at
your
colleague’s
family
practice
clinic.
SUDOSCAN
report
> Feet
Mean
ESC
69
μS,
0%
asymmetry
> Hands
Mean
ESC
63
μS,
29%
asymmetry
> Left
hand
ESC
is
73
μS
and
right
hand
ESC
is
52
μS
Discussion
Several
factors
may
be
contributing
to
a
peripheral
autonomic
neuropathy
in
this
patient.
Being
African
American,
her
scores
may
be
normal
though
lower
than
a
similar
Caucasian
patient.
On
this
scan,
her
feet
scores
appear
in
the
green
zone
and
are
considered
normal
for
her
racial
background.
This
is
reassuring
in
a
diabetic
patient
with
reasonable
control
of
her
diabetes.
Losing
some
weight
may
help
improve
this
score
further.
Her
hand
symptoms
and
SUDOSCAN
suggest
RIGHT
hand
dysfunction;
clinical
neurological
examination
will
most
likely
expose
a
carpal
tunnel
syndrome,
which
is
more
common
among
diabetics
than
the
general
population.
Appropriate
treatment
should
be
instituted
and
a
follow-‐up
SUDOSCAN
may
be
used
to
follow
therapeutic
effectiveness.