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Education  |   November 2016
Harlequin Syndrome Associated with Multilevel Intercostal Nerve Block
Author Notes
  • From the Miami Beach Anesthesiology Associates, Inc., Miami Beach, Florida; and Department of Anesthesiology, Mount Sinai Medical Center, Miami Beach, Florida.
  • Address correspondence to Dr. Viswanath: viswanoy@gmail.com
Article Information
Education / Images in Anesthesiology / Obstetric Anesthesia / Pediatric Anesthesia / Regional Anesthesia
Education   |   November 2016
Harlequin Syndrome Associated with Multilevel Intercostal Nerve Block
Anesthesiology 11 2016, Vol.125, 1045. doi:10.1097/ALN.0000000000001208
Anesthesiology 11 2016, Vol.125, 1045. doi:10.1097/ALN.0000000000001208
HARLEQUIN syndrome is characterized by clearly demarcated unilateral facial flushing and sweating caused by an injury to the sympathetic fibers to the face.1,2  Lesions creating the characteristic finding occur along the pathway connecting the hypothalamus, intermediolateral column of the spinal cord, cervical sympathetic ganglia, and postganglionic sympathetic fibers. Most of the sudomotor and vasomotor fibers innervating the face exit the spinal cord at the T2 to T3 level and continue along both the internal and external carotids.3  Injury along this pathway leads to facial anhidrosis and a loss of sympathetically mediated vasodilatation. The “normal” appearing side is actually the injured side. The contralateral side is thought to overcompensate creating the characteristic findings.1  Upper extremity involvement implies concomitant injury to superior thoracic sympathetic ganglia.3 
The patient in the figure developed Harlequin syndrome with upper extremity flushing and diaphoresis in the postanesthesia care unit 1 h after receiving left T3 to T11 intercostal nerve blocks with 0.25% bupivacaine for postoperative analgesia for thoracoscopic resection of the left lower lobe of the lung. Her vitals were at baseline, and she was neurologically intact. Her symptoms completely resolved in less than 12 h.
Harlequin syndrome may be seen after multilevel high thoracic intercostal nerve blocks. In the absence of hemodynamic instability or new neurologic findings, a central neurologic insult can be excluded, and reassurance is all that is required.3  We present this figure to educate fellow clinicians of this rare presentation of a typically benign, self-limited complication after multilevel high thoracic intercostal nerve block.
Competing Interests
The authors declare no competing interests.
References
Lance, JW, Drummond, PD, Gandevia, SC, Morris, JG Harlequin syndrome: The sudden onset of unilateral flushing and sweating.. J Neurol Neurosurg Psychiatry. (1988). 51 635–42 [Article] [PubMed]
Drummond, PD, Lance, JW Site of autonomic deficit in harlequin syndrome: Local autonomic failure affecting the arm and the face.. Ann Neurol. (1993). 34 814–9 [Article] [PubMed]
Wasner, G, Maag, R, Ludwig, J, Binder, A, Schattschneider, J, Stingele, R, Baron, R Harlequin syndrome—one face of many etiologies.. Nat Clin Pract Neurol. (2005). 1 54–9 [Article] [PubMed]