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Paroxysmal sympathetic hyperactivity in Pediatric Tuberculous meningitis: A New association

Objectives: To estimate the prevalence and analyse the clinico-radiologic profile of paroxysmal sympathetic hyperactivity (PSH) in pediatric tuberculous meningitis (TBM). Methods: Hospital records of children with TBM (as per International diagnostic criteria) from September 2019 through January 2022 were reviewed. Following the identification of the first case of PSH in TBM in September 2019, we screen TBM cases actively for PSH using PSH-assessment measure (PSH-AM). PSH was suspected when any of the following: recurrence of fever after initial defervescence, episodic or worsening posturing, dystonia, or tachycardia not explained by any other diagnosis, were present. PSH was graded as probable (≥ 17), possible (8-16) or unlikely (<8). Results: Forty-seven children with TBM got admitted during the study period, PSH was diagnosed in 6/47 (Table 1) (probable PSH-5; possible PSH-1). Clinical findings were hypertonia with episodic worsening-6/6; tachycardia-6/6; new onset fever-4/6; hypertension-4/6; tachypnoea-4/6; and diaphoresis-3/6. PSH appeared after a mean duration of 17 weeks (12-25 weeks) from diagnosis of TBM in 4/6 children and at 4-weeks in (2/6) children. On brain MRI, apart from basal exudates and hydrocephalus; periventricular white matter (6/6), thalamus(3/6), hypothalamus(3/6), brainstem(2/6) were involved. Medications used for management of PSH were morphine, clonidine, propranolol, dexmeditomidine and fentanyl. Hospital stay was prolonged in all children with probable PSH (Mean: 81.2 days) when compared to children with TBM without PSH (20.8 days). Conclusion: PSH is a late complication of TBM observed in 12.7% cases and should be anticipated in children with reappearance of fever and neurological worsening without any apparent cause.
Keywords: Tuberculous meningitis, Paroxysmal sympathetic hyperactivity, Neuro infection, Neurocritical care