Case Report: Dexmedetomidine for Intractable Clusters of Myoclonic Jerks and Paroxysmal Sympathetic Hyperactivity in Progressive Encephalomyelitis With Rigidity and Myoclonus

Paroxysmal sympathetic hyperactivity caused by neurosyphilis

Background

Paroxysmal sympathetic hyperactivity (PSH) is a condition characterised by dysregulation of the autonomic nervous system commonly associated with severe traumatic brain injury. Recently, non-traumatic causes, such as infections and autoimmune conditions, have also been reported as potential triggers.

Case presentation

A 30-year-old man presented with convulsions following 5 days of soliloquy, insomnia and agitation. Neurosyphilis was diagnosed based on elevated non-treponemal and treponemal test findings in the serum and cerebrospinal fluid. Intravenous penicillin administration improved his alertness; however, by day 9, he experienced recurrent episodes of tachycardia, tachypnoea, hyperthermia, hypertension, limb stiffness and diaphoresis. The exclusion of sepsis, pulmonary embolism and malignant syndrome, combined with unremarkable interictal electroencephalogram findings and a high PSH Assessment Measure Score, led to a PSH diagnosis on day 40. Treatment with propranolol, gabapentin and clonidine resolved the episodes, and the patient regained independent ambulation.

Conclusions

This is the first reported case of neurosyphilis accompanied by PSH. Although PSH is rare in central nervous system infections compared with traumatic brain injury, early recognition is crucial, as untreated cases can persist and result in severe complications.

The Role of Dexmedetomidine in Paroxysmal Sympathetic Hyperactivity: A Systematic Review

OBJECTIVE

The objective was to evaluate the efficacy and safety of dexmedetomidine in the treatment and prophylaxis of paroxysmal sympathetic hyperactivity (PSH).

DATA SOURCES

A review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria and queried Embase, MEDLINE (PubMed), Cochrane CENTRAL, Web of Science, SciELO, Korean Journal Index (Clarivate), Global Index Medicus, and CINAHL Plus for results through June 2023.

STUDY SELECTION AND DATA EXTRACTION

Studies providing efficacy or safety data associated with dexmedetomidine with a reported diagnosis of PSH were included. Exclusion of studies in pediatric populations, without quantitative and qualitative outcome data, and not readily translatable to English was adhered to.

DATA SYNTHESIS

Thirteen observational studies of 178 patients were included in the qualitative analysis. Reductions in PSH frequency or symptom severity were reported in 44 of 48 patients who received dexmedetomidine for acute treatment. Prophylactic use of dexmedetomidine was associated with reductions in PSH-Assessment Measure (PSH-AM) scores in postsurgical patients with traumatic brain injuries (TBIs). Adverse events associated with dexmedetomidine were either absent or reported as none.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

This review supports the safe and effective use of dexmedetomidine in the treatment and prophylaxis of PSH. Further investigation is required to determine optimal dosing strategies and the extent to which PSH etiology correlated to the efficacy of dexmedetomidine.

CONCLUSIONS

The use of dexmedetomidine appears to be both efficacious and safe for the treatment and prevention of PSH in patients experiencing a TBI. Additional research is needed to elucidate dosing strategies, titration parameters, and duration of therapy.

Dexmedetomidine improves lung compliance in patients undergoing lateral decubitus position of shoulder arthroscopy: A randomized controlled trial

BACKGROUND

The improvement of oxygenation and pulmonary mechanics in patients under general anesthesia can be achieved by dexmedetomidine (DEX) infusion. However, its role in patients undergoing lateral supine shoulder arthroscopy has not been thoroughly studied. This study aimed to evaluate the effect of DEX on lung compliance in patients undergoing shoulder arthroscopic surgery in a lateral decubitus position.

METHODS

The patients who underwent lateral recumbent shoulder arthroscopy under general anesthesia were randomly divided into the DEX group (group D) and the control group (group N). At the start of the trial, group D was given 0.5 μg/kg/hours continuous pumping until 30 minutes before the end of anesthesia; Group N was injected with normal saline at the same volume. The patients were recorded at each time point after intubation: supine position for 5 minutes (T0), lateral position for 5 minutes (T1), lateral position for 1 hour (T2), lateral position for 2 hours (T3), airway peak pressure, platform pressure, dynamic lung compliance, and static lung compliance, etc.

RESULTS

At the end of the drug infusion, the DEX group showed significant improved pulmonary mechanics and higher lung compliance than the control group. Compared with group N, group D's heart rate and mean arterial pressure were lower at all time points; there was no statistical difference in Tidal volume and Pressure end-tidal carbon dioxide data at each time point in Group D.

CONCLUSION

DEX can improve lung compliance and reduce airway pressure and platform pressure of patients undergoing shoulder arthroscopy in the lateral position under general anesthesia.

Case report: Varicella-zoster virus infection triggering progressive encephalomyelitis with rigidity and myoclonus

Progressive encephalomyelitis with rigidity and myoclonus (PERM) is a rare neurological disease of unknown etiology, and most patients with PERM are positive for anti-glycine receptor (GlyR) antibody. In this case study, we report a clinical case of a varicella-zoster virus-infected patient who developed anti-GlyR antibody-positive PERM. He initially suffered from herpes zoster and gradually developed symptoms of impaired brainstem functions including hoarse voice and dysphagia, accompanied by paroxysmal sympathetic hyperactivity. The patient also suffered from severe spasms, which were easily triggered by external stimuli. Glycine receptor antibodies were then found to be positive in serum and cerebrospinal fluid, and the diagnosis of PERM was confirmed. Methylprednisolone and gamma globulin treatments were given, and spasms were improved after treatment. Unfortunately, the patient's family insisted on automatic discharge and the patient passed away several days later.

Anti-glycine receptor antibody-positive progressive encephalomyelitis with rigidity and myoclonus initially presenting with one-sided stiff face: A case report

BACKGROUND

Progressive encephalomyelitis with rigidity and myoclonus (PERM) is a subtype of stiff-person syndrome, a rare cerebrospinal disease that causes brainstem symptoms, myoclonus, muscle rigidity, and hyperekplexia.

CASE PRESENTATION

A 71-year-old man experienced left-sided stiff face, and was subsequently admitted to our hospital because of the appearance of left-dominant lower limb myoclonus. Muscle rigidity followed 3 days later. Magnetic resonance imaging revealed no abnormality. An electrophysiological examination showed a toughness of the antagonistic muscle following evocation of the Achilles tendon reflex, and a tonic phenomenon affecting the left facial muscles during the blink reflex. The patient's serum was positive for anti-glycine receptor (anti-GlyR) antibody, suggesting PERM. The patient was administered steroids, immunoglobulin therapy, and immunosuppressive drugs. He gradually improved after these therapies and became able to walk using a walker.

CONCLUSIONS

We conclude that this was a rare case of anti-GlyR antibody-positive PERM with unilateral brainstem symptoms, myoclonus, and muscle rigidity.

Severe dysautonomia in glycine receptor antibody-positive progressive encephalomyelitis with rigidity and myoclonus (PERM): A case report

Progressive encephalomyelitis with rigidity and myoclonus (PERM) is a severe form of stiff-person spectrum disorder. We report a 59-year-old man who presented with progressive encephalomyelitis causing diplopia, bulbar palsy, severe dysautonomia, followed by stiffness and myoclonic cluster. Laboratory tests showed mild pleocytosis, with markedly elevated plasma levels of norepinephrine, epinephrine, and arginine vasopressin. Glycine-receptor antibodies were identified in both serum and CSF. Despite a poor response to methylprednisolone, immunoglobulins, and plasma exchange, α-blocker stabilized dysautonomia. Dysautonomia is presumed to be due to antibody-mediated disinhibited sympathetic hyperactivity; however, this case suggests that concomitant use of α-blocker with immunotherapy may ameliorate dysautonomia.