A 64-year-old man reported penile erection failure for approximately 7 years before consulting.
Six years ago, the patient presented with symptoms of orthostatic foot intolerance, mainly when the patient developed orthostatic foot intolerance and had lost consciousness at home; for this reason the patient was seated or seated.
1.
In addition, he used maneuvers such as bending the body forward and crossing the tapes to counteract the symptoms described above.
She reported no history of systemic disease or drug or drug use.
During the medical consultation, orthostatic hypotension was found and she was referred to our center.
Blood glucose, creatinine, blood count, plasma cortisol, thyroid function, plasma electrolytes, VDRL, ECG and echocardiogram were normal.
Outpatient blood pressure monitoring showed repeated episodes of hypotension during the day, while the patient had foot ulcers and episodes of nocturnal arterial hypertension when the patient was in the supine position.
Ultrasound examination revealed bladder and prostate gland with normal characters.
There was a mild to moderate degree post voiding recurrence (76 cc).
The peripheral nerves study showed normal conduction velocity.
Study of autonomic function.
Non-invasive studies of sympathetic and parasympathetic function were performed prior to the use of drugs4,5.
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Blood pressure and plasma noradrenaline.
Fasting blood pressure and basal noradrenaline blood level were measured before 60 min of rest in the supine position.
Then the patient stood up and blood pressure was measured every minute for five minutes and a sample of plasma noradrenaline at 5 min.
The value of noradrenaline in decubitus was very low (48 pg/ml) and did not increase when standing (24 pg/ml).
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thermoregulatory sweating.
Oral temperature was raised at 1°C and body sweating was explored with the Minor-Iodine test.
Absence of sweat in the left hemithorax and presence of compensatory hyperhidrosis on the right were found.
0003.
Sympathetic cutaneous response.
Deep inspiration stimulation was used and a biphasic cutaneous potential with decreased amplitude was obtained.
0004.
Maximal breathing.
The patient was in the supine position and breathed deeply for 5 s and sighed for 5 s.
The mean difference in heart rate (HR) variation in each cycle was calculated.
This variation in HR depends on an afferent and efferent pathway of the vagus nerve.
In the patient the variation was decreased (8 beats/min, the normal value is 310 beats/min).
0005.
Valsalva Index.
Patients were managed conservatively using a closed loop, glot, a mercury manometer (taken above 40 mmHg) for 15 s. Subsequently, the HRV was calculated using a closed loop recorder.
This HR variation depends on the integration of baroreceptors and vagus nerves.
This response was diminished in the patient (Valsalva index 1.0, normal value 31.5).
0006.
Indice 30:15.
The patient lifts and measures the variation of R-R during the first 30 beats when standing.
The index equals the longest R-R value around beat 30, by the shortest R-R within the first 15 beats.
This initial postural variation in HR depends on activation of baroreceptors and sympathetic-vagal balance.
In the patient this response was diminished (index 30:15 of 1.0, the normal value is 31.1).
Associated with the autonomic study, the patient has received fludrosome therapy and midazolam, achieving significant relief of symptoms of orthostatic intolerance.
