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Paroxysmal extreme pain disorder: a molecular lesion of peripheral neurons

Abstract

Background A 3-month-old male infant presented, beginning on the second day of life, with paroxysmal painful events that started with tonic contraction of the whole body followed by erythematous harlequin-type color changes.

Investigations Screening of the SCN9A gene, which encodes the voltage-gated sodium channel NaV1.7, identified a new mutation, Gly1607Arg, located within the domain IV S4 voltage sensor. Whole-cell patch-clamp analysis demonstrated functional effects of the mutant channel that included impaired inactivation—a hallmark of paroxysmal extreme pain disorder (PEPD).

Diagnosis The patient was diagnosed as having PEPD, an autosomal dominant disorder characterized by severe rectal pain triggered by defecation or perineal stimulation, usually followed by ocular or submaxillary pain. Erythematous flushing, sometimes in a harlequin pattern, can be a prominent feature of this condition.

Management Treatment with carbamazepine (10 mg/kg/day) for ≈3 months was ineffective in this case, and the parents made a decision to discontinue the drug. The mother was instructed to avoid painful stimuli that could trigger an episode.

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Figure 1: Harlequin flushing in the patient during episodes of paroxysmal extreme pain disorder.
Figure 2: PEPD-associated mutations in the NaV1.7 sodium channel.
Figure 3: Gly1607Arg substitution and NaV1.7 channel function.

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Acknowledgements

Written consent for publication was obtained from the patient's parents. We are grateful to Dr Caroline Espil-Taris for help in the diagnosis and treatment of our patient, and to Lynda Tyrrell for technical assistance. This work was supported in part by the Rehabilitation Research Service and Medical Research Service, Department of Veterans Affairs, and the Erythromelalgia Association. The Center for Neuroscience and Regeneration Research is a Collaboration of the Paralyzed Veterans of America and United Spinal Association with Yale University.

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J.-S. Choi, F. Boralevi, J. P. H. Drenth and S. G. Waxman researched data for the article and contributed to discussion of content, writing, and review and editing of the manuscript before submission. O. Brissaud researched data and contributed to discussion of content, review and editing of the manuscript. J. Sánchez-Martín researched data and contributed to the writing of the article. R. H. M. te Morsche researched data and contributed to review and editing of the manuscript. S. D. Dib-Hajj contributed to discussion of content, writing, and review and editing of the manuscript.

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Correspondence to Stephen G. Waxman.

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The authors declare no competing financial interests.

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Choi, JS., Boralevi, F., Brissaud, O. et al. Paroxysmal extreme pain disorder: a molecular lesion of peripheral neurons. Nat Rev Neurol 7, 51–55 (2011). https://doi.org/10.1038/nrneurol.2010.162

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