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Annals of Indian Academy of Neurology
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Year : 2022  |  Volume : 25  |  Issue : 3  |  Page : 340-346

Pure autonomic failure-A localized alpha synucleinopathy with a potential for conversion to more extensive alpha synucleinopathies


1 Consultant Neurologist, Kingston Upon Thames Hospital NHS Trust, London, India
2 MBBS, Senior Clinical Fellow in King's College Hospital NHS Trust, London, India

Correspondence Address:
Shakya Bhattacharjee
Consultant Neurologist, Kingston Upon Thames Hospital NHS Trust, London
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aian.aian_1078_21

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Pure autonomic failure (PAF) is an alpha synucleinopathy with predominant involvement of the autonomic ganglia and peripheral nerves. The hallmark clinical feature is orthostatic hypotension. However, genitourinary, sudomotor, and cardiac involvement is also common. Many patients also develop supine hypertension. Almost a quarter of patients can phenoconvert or evolve into Parkinson's disease, multiple system atrophy, and Lewy body dementia in the future. Early severe bladder involvement, higher supine noradrenaline level, early motor involvement, and dream enactment behavior increase the risk of phenoconversion. The diagnosis is confirmed via autonomic function testing and serum noradrenaline measurement. The treatment is mainly supportive. The non-pharmacological treatment includes adequate fluid, dietary salt, compression stockings, and abdominal binders. The drug therapies to improve blood pressure include midodrine, fludrocortisone, pyridostigmine, and droxidopa. The diagnostic criteria need to be updated to incorporate the recent understandings. The treatment of orthostatic hypotension and supine hypertension is mainly based on case series and anecdotal reports. Randomized control trials are needed to ascertain the best treatment strategies for PAF.


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