PAROXYSMAL SYMPATHETIC HYPERACTIVITY AS A CAUSE OF PROLONGED ICU STAY- CASE REPORT
ABHISHEK MEHAN, AKSHITA, ARNAB CHOUDHURY*, RIFIKA BANSAL, MUKESH BAIRWA
DEPARTMENT OF INTERNAL MEDICINE, ALL INDIA INSTITUTE OF MEDICAL SCIENCES, RISHIKESH, INDIA
*ARNAB CHOUDHURY, DEPARTMENT OF INTERNAL MEDICINE, ALL INDIA INSTITUTE OF MEDICAL SCIENCES, RISHIKESH, INDIA
Orcid ID: 0000-0001-5947-572X
Figure 1: Abnormal posturing
The patient was administered clonidine, propranolol, and baclofen. Her episodes of sympathetic hyperactivity were controlled . Later, her empirical antibiotics were stopped as there was no evidence of infection and fever was explained as a part of sympathetic hyperactivity. Antiepileptic medications were tapered off to only levetiracetam. However, after discontinuing valproate and lorazepam she again started experiencing episodes of sympathetic hyperactivity. Therefore, lorazepam was reintroduced to control her symptoms. Finally, the patient was weaned off ventilator support and shifted to the ward.
Blood parameters: TLC - 10,000 /mm3 ,Hb - 12 g/dl , Platelets - 2.8 lac/mm3
Blood culture - no pathogenic organism grown after 48 hrs of aerobic incubation.
Urine culture - sterile
Endotracheal aspirate culture - no pathogenic organism grown after 48 hrs of aerobic incubation.
High vaginal swab culture - normal vaginal flora grown.
Procalcitonin - 0.29 ng/ml
CSF analysis, - Acellular; sugar,-24 mg/dl; protein,-68 mg/dl; culture,-sterile
Dengue IGM,- negative; ICT and peripheral smear for Malaria - negative , Typhidot IGM,- negative; scrub typhus IGM,- negative.
Ultrasound abdomen:- no significant abnormality.
MRI Brain with MR Angiography –The brain stem appeared bulky and showed T2/FLAIR hyperintense signal. Similar areas with T2/ FLAIR hyperintense signal were also seen involving the thalami, right crus cerebri and bilateral inferior cerebellar peduncles. Many of these areas showed restricted diffusion with low Apparent Diffusion Coefficient (ADC) values. The bilateral (right > left) vertebral and distal basilar arteries appeared significantly attenuated in caliber. The right PCA appeared to be significantly attenuated in caliberas compared with fetal origin of the left PCA.
EEG - Generalized cerebral dysfunction; -no epileptiform-discharges.
CECT abdomen - No significant abnormality
Outcome and Follow-up
The episodes of sympathetic hyperactivity resolved, and the patient was shifted to the ward from the ICU with tracheostomy in room air. She developed contractures owing to persistent decerebrate posturing. Aggressive physiotherapy was administered. In the ward she regained her sensorium and was discharged with a GCS score of E4VTM6 for further follow-up in the OPD.
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