Seesaw dysautonomia: A manifestation of autonomic dysreflexia

A 58-year-old man with an incomplete C6/7 spinal cord injury due to traumatic injury 30 years earlier (American Spinal Injury Association Impairment Scale grade C) was referred for assessment of transient, alternating anisocoria. Initial examination revealed a 5-mm right pupil and 3-mm left pupil (figure 1A). Both pupils dilated in response to darkness (figure 1B), with no pupillary lag. The right pupil showed a lesser response to light (figure 1, C and D). The degree of anisocoria was reduced in the dark, suggesting the mydriatic pupil to be the abnormal one. There was no significant ptosis and eye movements were normal. There was evidence of unilateral hyperhidrosis affecting the right side of the face, upper chest, and proximal right arm. These episodes of hyperhidrosis had occurred intermittently since his injury and were interpreted as a manifestation of autonomic dysreflexia, occurring in association with hypertension (20–50 mm Hg above his baseline systolic blood pressure of 90–100 mm Hg), and often occurred in response to a noxious stimulus, usually to the contralateral side of the body.