1636 - Recurrent Micro Aspiration associated with Dystonia Masquerading as Paroxysmal Sympathetic Hyperactivity: A Case Report

A 23-year-old male with no significant past medical history was admitted to acute rehabilitation after an anoxic brain injury. His acute care course was notable for intermittent fevers, tachypnea, tachycardia, hypertension and involuntary movements which were all attributed to paroxysmal sympathetic hyperactivity. Regarding his fevers, infectious work up was negative, although he had intermittent leukocytosis. Upon admission to acute rehabilitation, he continued to have intermittent fevers, tachypnea, tachycardia, hypertension, and leukocytosis. He also continued to demonstrate involuntary movements consisting of twisting of his upper extremities and intermittent, forceful trunk and hip flexion. Early in his rehabilitation course he had a significant aspiration event. This was observed to result from truncal flexion during tube feedings. The patient was started on clonazepam for generalized dystonia and responded well to the medication. With abatement of the intermittent flexion of the trunk, the episodes of fevers, tachypnea, tachycardia, hypertension, and intermittent leukocytosis also resolved.

Discussions:

Although there was only one clear episode of aspiration during his acute rehabilitation course, the patient was likely having recurrent micro aspiration. This patient’s dystonic movements, including flexion of his trunk, especially during tube feeding, may have been causing this and thereby causing his intermittent fevers, leukocytosis, tachypnea and tachycardia. Additionally, the physical exertion from his constant movements contributed to his sweating, tachypnea, tachycardia, and hypertension also. Recurrent micro aspiration is not typically diagnosed with chest x-ray, and while bronchoscopy may show evidence of chronic aspiration, it is typically diagnosed clinically. In this case, resolution of the dystonic abdominal contractions also resolved the recurrent aspiration and conversely the other symptoms as well.

Conclusions:

Clinicians may benefit from reevaluating diagnosis of paroxysmal sympathetic hyperactivity (PSH), carefully considering overlap syndromes.