Diabetic gustatory sweating.ABSTRACT: Gustatory gus·ta·to·ry or gus·ta·tive
Of or relating to the sense of taste. sweating is a potential manifestation of autonomic dysfunction in diabetes. This syndrome is seen in long-standing diabetes and is associated with nephropathy nephropathy /ne·phrop·a·thy/ (ne-frop´ah-the) disease of the kidneys.nephropath´ic
analgesic nephropathy , peripheral neuropathy Peripheral Neuropathy Definition
The term peripheral neuropathy encompasses a wide range of disorders in which the nerves outside of the brain and spinal cord—peripheral nerves—have been damaged. , and other signs of dysautonomia. Symptoms of profuse pro·fuse
1. Plentiful; copious.
2. Giving or given freely and abundantly; extravagant: were profuse in their compliments. head and neck diaphoresis diaphoresis /di·a·pho·re·sis/ (-fah-re´sis) sweating, especially of a profuse type.
Perspiration, especially when copious and medically induced. with eating may suggest this clinical diagnosis. We present a patient who had complicated diabetes with symptoms of gustatory sweating and other evidence of dysautonomia. Diagnosis and treatment possibilities are discussed, with a review of the literature and an emphasis on bedside testing.
GUSTATORY SWEATING is a known manifestation of autonomic dysfunction in diabetes mellitus. (1-5) This syndrome is not only symptomatically disturbing to affected people, but also can affect glycemic Glycemic
The presence of glucose in the blood.
Mentioned in: Cholesterol, High
pertaining to the level of glucose in the blood. control. (1) Recognition of gustatory sweating is significant in that it provides an explanation for the symptoms, indicates possible concurrent diabetic complications, and allows the consideration of specific treatment modalities. Given the nonspecific nonspecific /non·spe·cif·ic/ (non?spi-sif´ik)
1. not due to any single known cause.
2. not directed against a particular agent, but rather having a general effect.
1. diagnosis of diabetic gustatory sweating, familiarity with this entity and other manifestations of autonomic dysfunction can help to elucidate the appropriate clinical context.
A 63-year-old African American man had a 20-year history of type 2 diabetes mellitus Type 2 diabetes mellitus
One of the two major types of diabetes mellitus, characterized by late age of onset (30 years or older), insulin resistance, high levels of blood sugar, and little or no need for supple-mental insulin. treated with insulin. Glycemic control had been suboptimal Suboptimal
A solution is called suboptimal if a part of the solution has been optimized without regards to the overall objective. , with home blood-glucose values ranging from 150 to 250 mg/dL and recent [HbA.sub.1c], level of 8%. Microvascular complications of the diabetes had been present for more than 10 years. He had peripheral neuropathy and vascular insufficiency, the latter requiring left below-the-knee amputation amputation (ăm'pyətā`shən), removal of all or part of a limb or other body part. Although amputation has been practiced for centuries, the development of sophisticated techniques for treatment and prevention of infection has greatly and right greattoe amputation. Serum creatinine level had ranged from 1.6 to 1.8 mg/dL for many years, and a urinary microalbumin-to-creatinine ratio was also high at 51 mg/g. Proliferative retinopathy had been treated with laser therapy. He also reported a several-year history of erectile dysfunction. He had an ejection fraction of 30% after a recent inferior myocardial infarction. In addition, he had had a cerebrovascular accident, with residual right upper neuron facial paresis paresis /pa·re·sis/ (pah-re´sis) slight or incomplete paralysis.
general paresis paralytic dementia; a form of neurosyphilis in which chronic meningoencephalitis causes gradual loss of cortical and partial ptosis Ptosis Definition
Ptosis is the term used for a drooping upper eyelid. Ptosis, also called blepharoptosis, can affect one or both eyes.
The eyelids serve to protect and lubricate the outer eye. . There was no other evidence of a Horner's syndrome.
The patient was admitted to the Veterans Affairs hospital with volume depletion accompanied by fatigue and dizziness. While management of the acute issues was addressed, a 4- to 5-year history of excessive diaphoresis with eating was elicited. The distribution of the sweating was in the head, neck, and upper chest and occurred 1 to 10 minutes after starting to eat any type of food. The diaphoresis lasted for 5 to 10 minutes after cessation of eating and was without related symptoms, except for a tendency to feel chilled. Environmental temperature did not appear to be related to the symptoms, and these episodes were not related to hypoglycemia hypoglycemia: see diabetes.
Below-normal levels of blood glucose, quickly reversed by administration of oral or intravenous glucose. Even brief episodes can produce severe brain dysfunction. (according to home glucose-monitoring). Sweating occurred at practically every meal and became enough of a social issue that the patient limited dining away from home. The patient was observed on several occasions to sweat with eating in the distribution and time frame described. Photographs were taken but did not clearly capture the findings, and no indicator substance was applied.
On physical examination, he was initially orthostatic orthostatic /or·tho·stat·ic/ (or?tho-stat´ik) pertaining to or caused by standing erect.
Relating to or caused by standing upright, as hypertension. by blood pressure level and pulse rate with presyncope. Upon position change from supine to standing, the heart rate increased from 75 to 90 beats per minute beats per minute Cardiac pacing The unit of measure for the frequency of heart depolarizations or contractions each minute–or pulse rate , while systolic blood pressure Systolic blood pressure
Blood pressure when the heart contracts (beats).
Mentioned in: Hypertension fell from 122 to 77 mm Hg. After cautious volume repletion re·ple·tion
1. The condition of being fully supplied or completely filled.
2. A state of excessive fullness. , these heart rate and blood pressure changes remained, though asymptomatically. To further investigate these findings, several basic tests of autonomic function were done (Table). The results supported the presence of dysautonomia.
This sweating continued to be a concern to the patient, and he requested therapy. Considering the multiple comorbid conditions and the patient's age in this case, systemic anticholinergic anticholinergic /an·ti·cho·lin·er·gic/ (-ko?lin-er´jik) parasympatholytic; blocking the passage of impulses through the parasympathetic nerves; also, an agent that so acts.
n. agents were undesirable. The patient was offered topical glycopyrrolate as a treatment for the gustatory sweating. Because of multiple reasons, he declined this option. Therefore, the efficacy of that modality cannot be assessed in this case.
Sweating is a normal physiologic function controlled by sympathetic cholinergic cholinergic /cho·lin·er·gic/ (ko?lin-er´jik)
1. parasympathomimetic; stimulated, activated, or transmitted by choline (acetylcholine); said of the sympathetic and parasympathetic nerve fibers that liberate acetylcholine at a pathways. (8) Thermoregulation Thermoregulation
The processes by which many animals actively maintain the temperature of part or all of their body within a specified range in order to stabilize or optimize temperature-sensitive physiological processes. is the priority of this autonomic function. (8) There are several conditions where sweating activity is inappropriate, ranging from hyperhidrosis to anhidrosis. Gustatory sweating itself is a unique entity characterized by profuse sweating of the face, scalp, and neck during or immediately after ingestion ingestion /in·ges·tion/ (-chun) the taking of food, drugs, etc., into the body by mouth.
1. The act of taking food and drink into the body by the mouth.
2. of food or drink. (1-3) No specific foods are consistently related to symptoms and reactions are variable. (3,4) This occurrence may be a source of embarrassment to patients and, in diabetic patients, may disturb eating patterns and thus impair glycemic control. (1) Pathophysiologically, this phenomenon has been explained as previously-denervated sweat glands becoming reinnervated with sympathetic or parasympathetic nerve function. (1-1,12) There is an apparent overcompensation overcompensation /over·com·pen·sa·tion/ (o?ver-kom?pen-sa´shun) exaggerated correction of a real or imagined physical or psychologic defect.
n. response from axonal axonal
pertaining to or arising from an axon.
an axon dies and cannot be replaced if its cell body is destroyed. regeneration that allows vasodilatory cholinergic sympathetic nerves to accomplish transmission. (3,4 ,12) Taste buds appear to be related to triggering symptoms, since placing food directly into the stomach does not evoke sweating. (3)
There are physiologic and nonphysiologic variants of gustatory sweating. (3) Physiologically, gustatory sweating may occur in temperate climates or with the ingestion of certain substances, including spicy foods.(1,3,12) Nonphysiologic forms include the auriculotemporal (Frey's) syndrome and diabetic gustatory sweating. The most commonly reported form is Frey's syndrome, which results from surgical or traumatic damage to the auriculotemporal nerve as it passes through the parotid gland. (1-4) In this case, symptoms are localized unilaterally to the distribution of the affected nerve. Frey's syndrome is not uncommon in certain surgical arenas, since it occurs in up to 60% of patients having parotidectomy Parotidectomy Definition
Parotidectomy is the removal of the parotid gland, a salivary gland near the ear.
The main purpose of parotidectomy is to remove cancerous tumors in the parotid gland. with facial-nerve dissection. (3,12)
Given that sweating is under autonomic control, abnormalities in people with advanced diabetes should not be surprising. (1,2,4,9,10) Dysautonomia is strongly related to duration and overall control of diabetes and portends an overall poor prognosis. (10) Extremes of anhidrosis and hyperhidrosis occur in 10% to 75% of people with diabetic autonomic neuropathy. (3) Upper body "compensotory hyperhidrosis" is observed in patients with peripheral neuropathy with distal anhidrosis. This is unrelated to eating or drinking, whereas diabetic gustatory sweating is a specific thermoregulatory disturbance directly related to oral intake. (3) Although the precise prevalence of gustatory sweating in diabetes is unknown, (3) it is documented much less commonly than surgical causes. This may be due in part to less frequent occurrence but is likely compounded by underrecognition and underreporting. Diagnosis of diabetic gustatory sweating relies on a high level of suspicion in an appropriate clinical setting. This phenomeno n is bilateral and is seen in long-standing diabetes with complications and other signs of dysautonomia. (3) No data suggest that level of glycemic control is related to severity of symptoms, though autonomic dysfunction in general is related to the level of metabolic stability. (4) One study of 196 patients with diabetes found some degree of gustatory sweating in 69% of patients with nephropathy and 36% of those with peripheral neuropathy. (4) In patients with renal insufficiency, gustatory sweating has been reversed with renal transplantation, though it occurs in the absence of diabetic nephropathy as well. (4) While no single test confirms the diagnosis of diabetic gustatory sweating, supporting evidence may be obtained by documenting the presence and distribution of diaphoresis. The increased moisture should appear during or after eating and be restricted to the head and neck region. This may be documented by application of a variety of indicator substances, including iodine starch and cobalt chloride str ips. (3,12)
Treatment of diabetic gustatory sweating has drawn on experience from surgical cases of Frey's syndrome. These approaches focus on symptomatic relief only and have no documented impact on the course of the syndrome or directly on glycemic control. Tight glycemic control also does not reverse existing dysautonomia. (9) Several systemic therapies have been used with varying degrees of success. Oral anticholinergic agents, including scopolamine scopolamine (skōpŏl`əmēn, –mĭn) or hyoscine (hī`əsēn', –sĭn), alkaloid drug obtained from plants of the nightshade family (Solanaceae), chiefly from henbane, , oxybutynin, propantheline, and glycopyrrolate, have improved symptoms (3,12); however, concurrent illnesses and adverse reactions, including mouth dryness, constipation, potential worsening of gastroparesis, and confusion, limit the use of systemic therapies. Clonidine clonidine /clo·ni·dine/ (klo´ni-den) a centrally acting antihypertensive agent, used as the hydrochloride salt; also used in the prophylaxis of migraine and the treatment of dysmenorrhea, menopausal symptoms, opioid withdrawal, and has also been used with some success but is also limited by side effects such as dry mouth and hypotension hypotension
or low blood pressure
Condition in which blood pressure is abnormally low. It may result from reduced blood volume (e.g., from heavy bleeding or plasma loss after severe burns) or increased blood-vessel capacity (e.g., in syncope). . (3) Such intolerability led to the investigation of nonsystemic approaches. Noting the efficacy of oral antimuscarinic agents, several investigators have used topical glycopyrrolate. (1,2,4,5,12) Th is quaternary ammonium compound quaternary ammonium compound
Any of a group of compounds in which a central nitrogen atom is joined to four organic radicals and one acid radical, used as antiseptics, solvents, and emulsifying agents.
Noun 1. has been shown to significantly decrease the incidence, severity, and frequency of sweating with eating' and is tolerated well. (2,12) Botulinum toxin has been used for gustatory sweating, though in most literature it is limited to use in unilateral, surgical-related cases. (13) In cases in which more conservative measures have failed and symptoms are disabling, surgery may be done; however, tympanic tympanic /tym·pan·ic/ (tim-pan´ik)
1. tympanal; of or pertaining to the tympanum.
2. bell-like; resonant.
1. neurectomy neurectomy /neu·rec·to·my/ (ndbobr-rek´tah-me) excision of a part of a nerve.
Surgical removal of a nerve or part of a nerve. or subdermal sub·der·mal
Located or placed beneath the skin; subcutaneous. fascia grafts are invasive, difficult procedures and have varying, and often temporary, efficacy. (12)
Gustatory sweating is a common, albeit underrecognized, manifestation of diabetic autonomic dysfunction. This should be considered in any presentation of excessive diaphoresis in a patient with a long duration of diabetes mellitus. Diagnosis, although nonspecific, relies on taking a careful history and exploration for other evidence of dysautonomia. Symptomatic treatments with well-documented efficacy are available in various dosage forms.
TABLE. Selected Bedside Evaluations of Autonomic Nervous System Function Type of Test Name of Test How Test Performed Parasympathetic Basal HR (6,7) Compare resting HR CV system with control testing Valsalva Have patient bear ratio (6,8-10) down for 15-30 seconds or blow against manometer to 40 mL for 10-15 seconds and compare R-R interval on marked EGG with baseline HR changes Monitor HR on marked with deep ECG while patient inspiration (6,8-9) takes 6 deep breaths per minute Postural HR Obtain HR after changes (6,8-11) standing from supine position Carotid sinus Firm pressure on massage (8,10) unilateral carotid artery and observe HR Sympathetic Postural BP Obtain BP after CV System changes (7-11) standing from Testing supine position Dysautonomic Type of Test Normal Response Response Parasympathetic Higher basal HR CV system testing Ratio of longest: Valsalva ratio <1.4 shortest R-R interval (Valsalva ratio) >1.4 when comparing R-R during rest and during the Valsalva R-R will increase Minimal R-R with inspiration variability with respiration R-R interval 30:15 ratio <1.04 should increase 11-29 bpm by the 15th heartbeat after standing and then slow by the 30th beat (30:15 ratio should be >1.04) HR should fall HR will not appreciably change Sympathetic SBP decreases SBP decreases CV System <30 mm Hg and >30 mm Hg or Testing DBP decreases DBP decreases <15 mm Hg > l5 mm Hg Case Study Type of Test Response Parasympathetic Average HR 80-85 CV system bpm testing Valsalva ratio 1.0 No R-R variability with deep inspiration 30:15 ratio = 0.90 No appreciable HR changes Sympathetic SBP fell 45 mm Hg CV System upon standing from Testing supine position CV = Cardiovascular, HR = heart rate, bpm = beats per minute, R-R interval = measured distance between R waves on electrocardiogram strips, ECG = electrocardiogram, BP = blood pressure, SBP = systolic blood pressure, DBP = diastolic blood pressure.
(1.) Atkin SL, Brown PM: Treatment of gustatory sweating with topical glycopyrrolate cream. Diabetic Med 1996; 13:493-494
(2.) Urman JD, Bobrove AM: Diabetic gustatory sweating successfully treated with topical glycopyrrolate. Arch Intern Med 1999; 159:877-878
(3.) Sheehy TW: Diabetic gustatory sweating. Am J Gastroenterol 1991; 86:15-17
(4.) Shaw JE, Parker R, Hollis S, et al: Gustatory sweating in diabetes mellitus. Diabetic Med 1996; 13:1033-1037
(5.) Shaw JE, Abbott GA, Tindle K, et al: A randomized ran·dom·ize
tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es
To make random in arrangement, especially in order to control the variables in an experiment. , controlled trial of topical glycopyrrolate, the first specific treatment for diabetic gustatory sweating. Diabetologia 1997; 40:299-301
(6.) Dryberg T, Benn J, Christianson JS, et al: Prevalence of diabetic autonomic neuropathy measured by simple bedside tests. Diabetologia 1981; 20:190-194
(7.) Engstrom J, Martin JB: Disorders of the autonomic nervous system autonomic nervous system: see nervous system.
autonomic nervous system
Part of the nervous system that is not under conscious control and that regulates the internal organs. It includes the sympathetic, parasympathetic, and enteric nervous systems. . Harrison s Principles of Internal Medicine. Fauci AS, Braunwald E, Isselbacher KJ, et al (eds). New York, McGraw-Hill, 14th Ed, 1998, pp 2372-2375
(8.) Saper CB: Autonomic disorders and their management. Cecil's Textbook of Medicine. Goldman L, Bennett JC (eds). Philadelphia, WB Saunders Go, 21st Ed, 2000, pp 2057-2066
(9.) Stevens MJ: Diabetic autonomic neuropathy. [On UpToDate CD-ROM CD-ROM: see compact disc.
in full compact disc read-only memory
Type of computer storage medium that is read optically (e.g., by a laser). ]. UpToDate 1999; 7:1-11
(10.) Young JB, Landsberg L: Catecholamine catecholamine (kăt'əkôl`əmēn), any of several compounds occurring naturally in the body that serve as hormones or as neutrotransmitters in the sympathetic nervous system. and the adrenal medulla. Williams Textbook of Endocrinology. Wilson JD, Foster DW, Kronenberg HM, et al (eds). Philadelphia, WB Saunders Go, 9th Ed, 1998, pp 703-705
(11.) McLeod JG, Tuck RR: Disorders of the autonomic nervous system. Part 2: Investigation and treatment. Ann Neurol 1987; 21:519-529
(12.) Hays LL, Novack AJ, Worsham JC: The Frey syndrome: a simple, effective treatment. Otolaryngol Head Neck Surg 1982; 90:419-425
(13.) Naumann M: Evidence-based medicine: botulinum toxin in focal hyperhidrosis. J Neurology 2001; 248(suppl 1)31-33
RELATED ARTICLE: KEY POINTS
* Gustatory sweating is a unique clinical diagnosis.
* Gustatory sweating is potentially disabling to patients.
* Gustatory sweating is a sign of more generalized autonomic dysfunction in diabetes.
* Several treatment options exist for gustatory sweating.
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