Late postoperative harlequin syndrome coexisting with horner syndrome after thoracic epidural anesthesia

A patient who underwent left mastectomy under thoracic epidural anesthesia developed transient ipsilateral well-demarcated hemifacial erythema, sweating, and contralateral Horner syndrome postoperatively. All the clinical features subsided and had completely resolved within 24 hours after the cessation of patient-controlled epidural analgesia with bupivacaine 0.05% and fentanyl 0.5%. We believe that the reason for the excessive highlevel thoracic sympathetic blockade that led to this concomitant syndrome was cephalad spread of local anesthetic.