Shy-Drager Syndrome

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Shy-Drager Syndrome

Definition

Shy-Drager syndrome (SDS) is a rare condition that causes progressive damage to the autonomic nervous system. The autonomic nervous system controls vital involuntary body functions such as heart rate, breathing, and intestinal, urinary, and sexual functions. The autonomic nervous system also controls skin and body temperature, and how the body responds to stress. Shy-Drager syndrome leads to dizziness or fainting when standing up, urinary incontinence, impotence, and muscle tremors.

Description

SDS was named for neurologists Milton Shy, M.D., from the National Institutes of Health, and Glenn Drager, M.D., from the Baylor College of Medicine, who first described the condition in 1960. It typically affects those between ages 50-70. It affects more men than women. In severe cases, the person cannot even stand up. Symptoms can be mild as well. Sometimes, people with mild cases are misdiagnosed as having anxiety or hypertension.

Many nonprescription drugs, such as cold medicines and diet capsules, can trigger extremely high blood pressure spikes in patients with SDS, even in very low doses. Therefore, these patients are at risk for strokes and excessive bleeding (hemorrhage) if they take even the recommended dosage of these drugs.

Causes and symptoms

The cause of SDS is unknown. Symptoms develop because of degeneration of certain groups of nerve cells in the spinal cord.

Patients with SDS usually have problems with the function of the autonomic nervous system. Progressive degeneration may occur in other areas of the nervous system as well. The hallmark of the syndrome is dizziness and fainting when arising or after standing still for a long time (postural hypotension ). This is caused by low blood pressure and inadequate blood flow to the brain. When this problem becomes severe (for example, a blood pressure below 70/40 mmHg), it can lead to a momentary loss of consciousness. When the person faints, the blood pressure returns to normal and the person wakes up.

Many patients also notice impotence, urinary incontinence, dry mouth and skin, and trouble regulating body temperature because of abnormal sweating. Since the autonomic nervous system also controls the narrowing and widening of the iris, some patients with SDS have vision problems, such as trouble focusing.

In later stages, problems in the autonomic nervous system lead to breathing difficulties such as sleep apnea, loud breathing, and snoring. In advanced stages of the disease, patients can die from irregular heartbeat.

Other symptoms of SDS do not involve the autonomic nervous system. These include parkinsonism (muscle tremor, rigidity, and slow movements), double vision, problems controlling emotions, and wasting of muscles in the hands and feet. Eventually, patients may have problems chewing, swallowing, speaking, and breathing. There may be a loss of color pigment in the iris.

Diagnosis

While no blood test can reveal the disorder, a careful assessment of symptoms should alert a neurologist to suspect SDS. A combination of parkinsonism and certain autonomic problems (especially impotence, incontinence, and postural hypotension) are clear indications of the syndrome.

Tests of the autonomic nervous system may help diagnose the condition. In normal patients, blood levels of norepinephrine rise when they stand up. This doesn't happen in people with SDS. Norepinephrine is a hormone that helps maintain blood pressure by triggering certain blood vessels to constrict when blood pressure falls below normal. Another test for the condition is the Valsalva maneuver. In this test, the patient holds his or her breath and strains down as if having a bowel movement while the doctor monitors blood pressure and heart rate for 10 seconds. Patients with SDS will not have the normal increase in blood pressure and heart rate.

A variety of other tests can identify a broad range of autonomic problems in patients with SDS. Brain scans, however, don't usually reveal any problems.

Treatment

Medication can relieve many of the symptoms, especially the parkinsonism and low blood pressure. However, typical antiparkinsonism drugs such as carbidopa-levodopa (Sinemet) should be used with caution, since they often worsen the postural low blood pressure and may cause fainting.

Because postural hypotension is the most troublesome of the symptoms in the early years, treatments center on relieving this problem. Patients are encouraged to eat a liberal salt diet and drink plenty of fluids. They are advised to wear waist-high elastic hosiery and to sleep with the head elevated at least 5 in (13 cm). Other drug treatment includes fludrocortisone, indomethacin, nonsteroidal anti-inflammatory drugs, beta blockers, central stimulants, and other medications.

Occasionally, a pacemaker, gastrostomy, or tracheostomy may be needed. A pacemaker is a device that delivers electrical impulses to the heart to keep it beating regularly. A gastrostomy creates an opening in the stomach to connect a feeding tube from outside the body. In a tracheostomy an opening is made in the windpipe and a tube is inserted to maintain breathing.

Prognosis

While the course of the disease varies, and some patients live for up to 20 years after the symptoms first appear, most patients become severely disabled within seven or eight years. It is unusual for someone to survive more than 15 years after diagnosis.

Symptoms (especially tremor) often get worse if the patient smokes, because of the nicotine.

Many patients develop swallowing problems which may lead to recurrent episodes of pneumonia, a frequent cause of death. Others experience Cheyne-Stokes (periodic breathing). One of the most common causes of death is pulmonary embolus. This is caused by a blood clot in the main artery in the lung.

KEY TERMS

Autonomic nervous system— The part of the nervous system that controls the involuntary (apparently automatic) activities of organs, blood vessels, glands, and many other body tissues.

Degenerative— Degenerative disorders involve progressive impairment of both the structure and function of part of the body.

Gastrostomy— An artificial opening into the stomach through the abdomen to enable a patient to be fed via a feeding tube. The procedure is given to patients with SDS who are unable to chew or swallow.

Norepinephrine— A hormone that helps maintain blood pressure by triggering certain blood vessels to constrict when blood pressure falls below normal.

Sleep apnea— A sleep disorder characterized by periods of breathing cessation lasting for 10 seconds or more.

Tracheostomy— An opening through the neck into the trachea through which a tube may be inserted to maintain an effective airway and help a patient breathe.