Key result
Combination therapy for paroxysmal sympathetic hyperactivity yields initial improvement but ends in fatal cardiac arrest.
Why the study?
Paroxysmal sympathetic hyperactivity (PSH) diagnosis relies on clinical scoring due to lack of confirmatory tests, and treatment requires multiple drugs to control catecholamine surge.
Case Report (n=1)
No
A combination of morphine, diazepam, propranolol, and gabapentin can be used to manage paroxysmal sympathetic hyperactivity following intracranial hemorrhage, though underlying complications may remain fatal.
BACKGROUND: Paroxysmal sympathetic hyperactivity (PSH) is a neurologic syndrome characterized by paroxysmal and simultaneous occurrence of hypertension, hyperpyrexia, tachycardia, tachypnea, diaphoresis and dystonic posturing due to surge in sympathetic outflow after acquired brain injuries. Diagnosis of PSH is made using the paroxysmal sympathetic hyperactivity-assessment measure (PSH-AM) score, which comprises "clinical features severity" (CFS) score and "diagnosis likelihood tool" (DLT) score. CASE PRESENTATION: A 35-year-old woman diagnosed to have echo-proven chronic rheumatic heart disease for 25 years. Percutaneous balloon mitral valvotomy was done 6 weeks previously for severe mitral stenosis. Left atrial thrombus was detected after the procedure and anticoagulant (warfarin) was initiated. She presented with severe headache and repeated vomiting of 1 day duration on arrival to the hospital. She had frequent seizure attacks with subsequent loss of consciousness on third day of admission. Diagnosis of status epilepticus secondary to intracranial hemorrhage due to warfarin toxicity was made after CT-scan revealed acute subdural hematoma and ventricular bleeding. Then she was transferred to medical intensive care unit (ICU), intubated and put on mechanical ventilator. Anti-epileptic drugs, antibiotics, vitamin K and fresh frozen plasma were given. She developed paroxysms of hypertension, tachycardia, tachypnea, hyperpyrexia, diaphoresis and decerebrate posturing after 7 days of neurological insult. She had normal inter-ictal EEG tracing during cyclic autonomic surge. CFS score was 11 and DLT score was 10. In sum, PSH-AM score was 21, suggested "probable" diagnosis of PSH. Morphine, diazepam, propranolol and gabapentin were given in combination to treat PSH. Severity of autonomic storm started to improve on second week of ICU admission. On the third week of admission, her clinical condition deteriorated suddenly, she developed asystole and died of cardiac arrest despite cardiopulmonary resuscitation (CPR). CONCLUSION: 'Clinical scoring' was used used to diagnose PSH, since there was no any confirmatory test. Cocktail of drugs were required to treat catecholamine surge in PSH.
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Bekele et al. (2020) conducted a case report in Paroxysmal Sympathetic Hyperactivity (n=1). Morphine, diazepam, propranolol and gabapentin was evaluated. A 35-year-old woman with paroxysmal sympathetic hyperactivity treated with morphine, diazepam, propranolol, and gabapentin showed initial improvement but ultimately died of cardiac arrest.