Iatrogenic harlequin syndrome resulting from sympathectomy

Postgrad Med J 2003;79:278 doi:10.1136/pmj.79.931.278

A 29 year old man with severe facial hyperhidrosis underwent an uncomplicated right thoracoscopic sympathectomy. Before operating on his left side, a starch-iodine preparation was applied to his face in order to demarcate residual sudomotor function. The preparation becomes blue on exposure to moisture, thereby representing residual sweat gland activity.

Figure 1 demonstrates that sympathetic innervation to the face is strictly unilateral, and nerve fibres do not appear to cross the midline. This is essentially an iatrogenic variation of the harlequin syndrome,² which usually results from interruption of post-ganglionic sympathetic fibres secondary to malignant invasion.

His facial hyperhidrosis was completely treated once the contralateral sympathectomy was performed.