Paroxysmal Sympathetic Hyperactivity: An Old but Unrecognized Condition

Abstract

Patients who survive a traumatic brain injury (TBI) can sometimes experience symptoms of excessive sympathetic discharge. Despite being known about for more than 60 years, the diagnostic criteria for this condition have only recently been defined under the name "paroxysmal sympathetic hyperactivity". Failure to recognize this syndrome leads to excessive costs, prolonged hospital stays and delayed recovery for TBI patients. This case report describes a patient whose specific rehabilitation program was affected by a failure to identify this entity, even though he presented with many of the characteristics of this condition. LEARNING POINTS• Fever is a common sign in hospitalized patients and can result in expensive investigations and prolong length of stay.• It is crucial to consider paroxysmal sympathetic hyperactivity (PSH) as a cause of fever in traumatic brain injury patients (TBI).• A delay in diagnosing and treating PSH can have devastating consequences for these patients' recovery programs. KEYWORDS Paroxysmal sympathetic hyperactivity (PSH), traumatic brain injury (TBI), fever, beta-blocker CASE PRESENTATION The authors report the case of 27-year-old male who was aphasic and tetraplegic following a traumatic brain injury (TBI) with severe right hemisphere lesions sustained in a road traffic collision. Five months after the accident, the patient was readmitted to hospital because of nosocomial pneumonia and was started on a 10-day course of the antibiotic meropenem. No pathogens were isolated from blood or sputum cultures and the patient improved clinically to be stable on air, with no respiratory symptoms and negative inflammatory markers. Despite the apparently treated infection, the patient was still febrile with his temperature rising to 39.5°C once or twice a day with very little response to antipyretic drugs. During these episodes, the patient became tachycardic, hypertensive, tachypnoeic and sweated profusely. The patient´s mother reported that these episodes were also frequent at home and that because of them, the patient had been refused care in a specialized rehabilitation hospital as he was thought to be infectious. A complete septic screen was performed including blood, sputum (obtained from bronchoscopy), urine and liquor samples but no bacteria, yeast or fungus were found, and no changes were seen on imaging tests. The inflammatory markers were also negative: white cell count 7,000×10 9 /l (normal value <11,000×109/l), C-reactive protein <0.5 mg/dl (normal value <0.5 mg/dl) and erythrocyte sedimentation rate 23 mm/h (normal value <20 mm/h). Both renal and liver function were normal. Paroxysmal sympathetic hyperactivity (PSH) was then considered as the cause of the patient's febrile episodes. PSH is a common but unrecognized complication after TBI and is characterized by hypertension, tachycardia, sweating, tachypnoea and hyperthermia, the last

Paroxysmal Sympathetic Hyperactivity in Moderate-to-Severe Traumatic Brain Injury and the Role of Beta-Blockers: A Scoping Review

“…However, the randomized controlled trial did not confirm the causal link between beta-blocker therapy and reduced mortality or length of stay [ 11 ]. Of note, beta-blockers were often used in combination with other drugs to manage post-TBI PSH ( Table 1 ) [ 7 , 9 , 21 – 23 ].…”

“…e role of beta-blockers in the management of PSH following moderate-to-severe TBI is a fairly recent concept. Before 2010, there was a single study [21], but nine studies have since been published [7,9,11,[22][23][24][25][26][27]. e studies were mostly systematic reviews without meta-analysis (40%) [7,9,22,25] and case reports (30%) [21,26,27].…”

“…Before 2010, there was a single study [21], but nine studies have since been published [7,9,11,[22][23][24][25][26][27]. e studies were mostly systematic reviews without meta-analysis (40%) [7,9,22,25] and case reports (30%) [21,26,27]. Only two studies evaluated the impact of beta-blockers on post-TBI PSH-related mortality, showing that beta-blocker therapy improved mortality [25].…”

Paroxysmal Sympathetic Hyperactivity Syndrome (Review)

“…Для описания этих состояний использовались различные термины: диэнцефальные припадки, центральная вегетативная дисрегуляция, гиперадренергическое состояние, синдром среднего мозга, синдром вегетативной дисфункции, дизавтономия, вегетативная буря (шторм), симпатический шторм, диэнцефально-катаболический синдром (ДКС) и др. [2][3][4][5][6][7]. В Российском научноисследовательском нейрохирургическом институте им.…”