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 7,000x109/l (normal value <11,000x109/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 being less frequent than the other signs.
A consensus statement was issued only recently on the definition, nomenclature and diagnostic criteria for PSH, an entity that was previously poorly recognized, thus leading to delays in treatment and increased morbidity among TBI patients. In this consensus, an assessment measure was proposed combining a "Clinical Feature Scale" and a "Diagnosis Likelihood Tool". Our patient scored 22 points in this proposed model, indicating a 'Probable' PSH diagnosis (Table 1).
Current state-of-the art treatment for this condition with beta-blockers was initiated with propranolol 10 mg every 8 hours up-titrated to 30 mg every 6 hours on discharge. The patient experienced complete resolution of all the described symptoms and no negative beta-blocker side-effects were noticed.