Paroxysmal Sympathetic Storm

Diamond, Alan; Callison, R Charlie; Shokri, Jahansouz; Cruz‐Flores, Salvador; Kinsella, Laurence J.

doi:10.1385/ncc:2:3:288

Cited by 28 publications

(28 citation statements)

References 10 publications

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“…Next to the treatment of the underlying cause the central sympathetic pathways may be controlled by morphine, bromocriptine [5,9,13,14], clonidine or a non-selective beta-blocker [6,13-15]. Benzodiazepines can also be effective, as in our patient [1,16]. Dantrolene can decrease fever due to prolonged muscle contraction [11,16].…”

Section: Discussionmentioning

confidence: 99%

Paroxysmal autonomic instability with dystonia in a patient with tuberculous meningitis: a case report

Ramdhani¹,

Sikma

Witkamp

et al. 2010

J Med Case Reports

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IntroductionThis case report describes an extremely rare combination of paroxysmal autonomic instability with dystonia and tuberculous meningitis. Paroxysmal autonomic instability with dystonia is normally associated with severe traumatic brain injury.Case presentationA 69-year-old man of Indonesian descent was initially suspected of having a community-acquired pneumonia, which was seen on chest X-ray and computed tomography of the chest. However, a bronchoscopy showed no abnormalities. He was treated with amoxicillin-clavulanic acid in combination with ciprofloxacin. However, nine days after admission he was disorientated and complained of headache. Neurological examination revealed no further abnormalities. A lumbar puncture revealed no evidence of meningitis. He was then transferred to our hospital. At that time, initial cultures of bronchial fluid for Mycobacterium tuberculosis turned positive, as well as polymerase chain reaction for Mycobacterium tuberculosis. Later, during his stay in our intensive care unit, he developed periods with hypertension, sinus tachycardia, excessive transpiration, decreased oxygen saturation with tachypnea, pink foamy sputum, and high fever. This constellation of symptoms was accompanied by dystonia in the first days. These episodes lasted approximately 30 minutes and improved after administration of morphine, benzodiazepines or clonidine. Magnetic resonance imaging showed an abnormal signal in the region of the hippocampus, thalamus and the anterior parts of the lentiform nucleus and caudate nucleus.ConclusionsIn patients with (tuberculous) meningitis and episodes of extreme hypertension and fever, paroxysmal autonomic instability with dystonia should be considered.

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Section: Discussionmentioning

confidence: 99%

Paroxysmal autonomic instability with dystonia in a patient with tuberculous meningitis: a case report

Ramdhani¹,

Sikma

Witkamp

et al. 2010

J Med Case Reports

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“…Adrenergic disinhibition has been successfully treated with alpha-1 adrenergic or beta adrenergic blockade [1,[9][10][11]. Additionally, benzodiazepine, opioid agonists, dopamine agonists, intrathecal baclofen, and muscle relaxants have been used [1,[11][12][13].…”

Section: Discussionmentioning

confidence: 99%

Dexmedetomidine for the treatment of paroxysmal autonomic instability with dystonia

2007

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“…An intracranial pressure monitor was placed, and intracranial pressures were wellcontrolled over the next several days without requiring any interventions. Three days after the accident, the patient developed intermittent episodes of tachycardia with tachypnea, hypertension, fever, profuse sweating, and brisk extensor posturing, consistent with paroxysmal sympathetic hyperactivity [2, 3] (Video in Supplementary material).Paroxysmal sympathetic hyperactivity (PSH) can occur following traumatic brain injury with axonal shear injury, due to disinhibition of subcortical sympathoexcitatory structures [3]. This may have an early and late onset, and is most frequently seen in younger patients.…”

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Paroxysmal Sympathetic Hyperactivity After Traumatic Brain Injury

et al. 2010

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A 35-year-old male was the unrestrained driver in a rollover motor vehicle accident from which he was ejected. He was initially comatose, with anisocoria and bilaterally unreactive pupils, absent oculocephalic, corneal, cough and gag reflexes, and no motor response to painful stimulus, but initiating respirations on his own (GCS 3T, FOUR score E0 M0 B0 R1 [1]). Shortly after admission, he developed extensor posturing, elevating his exam to GCS 4T, FOUR score E0 M1 B0 R1. However, his exam did not improve further. Head CT demonstrated small petechial hemorrhages at the gray/white junction, corpus callosum, basal ganglia, and in the interpeduncular cistern, consistent with diffuse axonal injury (Fig. 1). An intracranial pressure monitor was placed, and intracranial pressures were wellcontrolled over the next several days without requiring any interventions. Three days after the accident, the patient developed intermittent episodes of tachycardia with tachypnea, hypertension, fever, profuse sweating, and brisk extensor posturing, consistent with paroxysmal sympathetic hyperactivity [2, 3] (Video in Supplementary material).Paroxysmal sympathetic hyperactivity (PSH) can occur following traumatic brain injury with axonal shear injury, due to disinhibition of subcortical sympathoexcitatory structures [3]. This may have an early and late onset, and is most frequently seen in younger patients. The classic features of these episodes include at least four of the following: profuse sweating, tachycardia, hypertension, tachypnea, fever and extensor posturing, and occur transiently without any other cause [4]. PSH has been previously called diencephalic seizures, but EEGs in these patients have always been normal. The typical clinical features were present in our patient, and were never associated with twitches or decrease in responsiveness that may indicate seizures.PSH typically responds most effectively to a combination of opiate agonist and nonselective beta blockade [4,5]. Bromocriptine and clonidine may also be used, but with less consistent results [4,5], and gabapentin is gaining more widespread use for long term effectiveness. In our patient, the episodes were initially treated with beta blockade with propranolol, but did not respond. A combination of clonidine and morphine given during acute episodes was most effective in halting them. Gabapentin was started two days later for longer-term control. However, his neurologic exam failed to improve, care was withdrawn at the strong request of the family and he expired soon after extubation. Paroxysmal sympathetic hyperactivity is a common occurrence in catastrophic neurologic injuries leading to persistent vegetative state. These manifestations are often mistaken for rigors or convulsions and are commonly inadequately treated.Electronic supplementary material The online version of this article (

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Paroxysmal Sympathetic Storm

Abstract: These observations underscore the importance of central opioid receptors and nonselective beta-adrenergic antagonists in modulating catecholamine pathways.

Cited by 28 publications

References 10 publications

Paroxysmal autonomic instability with dystonia in a patient with tuberculous meningitis: a case report

Paroxysmal autonomic instability with dystonia in a patient with tuberculous meningitis: a case report

Dexmedetomidine for the treatment of paroxysmal autonomic instability with dystonia

Paroxysmal Sympathetic Hyperactivity After Traumatic Brain Injury

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