Paroxysmal sympathetic hyperactivity in tubercular meningitis: An underacknowledged association

Introduction Paroxysmal sympathetic hyperactivity (PSH) is most commonly associated with traumatic brain injury. PSH in CNS infections has been quoted variably due to extremely low numbers of its occurrences. With this article, we document a case report of a patient admitted with PSH secondary to tubercular meningitis (TBM), with an attempt to highlight the burden of disease. Clinical discussion The pathophysiology of PSH is yet to be clearly understood and clinical presentation is ambiguous leading to a delay in identification and, therefore, a delay in management. Despite using the diagnostic tool, PSH forms a diagnosis of exclusion. Management involves supportive care, pharmacological therapy and, surgical intervention for raised ICP. Detailed analysis of the handful of known cases showcases the grave morbidity this condition carries. Case report An 11-year-old female child diagnosed with TBM underwent ventriculoperitoneal shunt surgery and was stable in the immediate post-operative period. After 3 days, the patient developed episodes of high-grade fever with diaphoresis, tachycardia and hypertension, which continued to deteriorate despite aggressive management. Her PSH-Assessment Measure (PSH-AM) score was 26 (probable). Unfortunately, the patient eventually succumbed to the disease. Conclusion In decreasing order, the manifestations were tachycardia (100%), tachypnea, dystonia, hyperthermia, hypertension and diaphoresis, with a predilection in males of pediatric age. Keeping a low threshold for diagnosis and early detection is essential for reducing long-term neurological sequelae. Our case report is the 7th case in the literature of PSH in TBM (unrelated to hydrocephalus) and the 15th case of PSH in TBM including those where hydrocephalus played a role.