705 - Paroxysmal Autonomic Instability with Dystonia Following Anoxic Brain Injury

Case Diagnosis: Paroxysmal autonomic instability with dystonia (PAID)

Case Description: The patient is a 31-year-old male who presented 4 months after severe anoxic brain injury from a suicide attempt. Following acute care, he was discharged to an ECF, and brought back with fever, tachycardia, tachypnea, diaphoresis, and hypertonia, with extensor posturing. He was initially started on Percocet and valproate, with wound care for a sacral ulcer. On evaluation by PM&R, he was in bed having muscle spasms causing him to slide in bed but was alert, following commands and responding appropriately with small movements facial and head movements. He was started on Dantrolene, Valium, Bromocriptine, Propranolol, and Baclofen, with Percocet and Morphine for pain control. He had significant improvements the following day with comfort, tone, and sympathetic hyperactivity. Gabapentin and Dilaudid were added, and medications were titrated during hospitalization. Five months later, the patient was seen in clinic, with continued extensor tone, but continued improvements with posturing and responsiveness.

Discussions: PAID syndrome is a severe diagnosis, most often presenting after traumatic or hypoxic brain injuries, increasing morbidity and mortality. Although the pathophysiology is not fully understood, it may be explained by dysfunction within autonomic regulation centers.¹ Patients present with symptoms of autonomic instability such as agitation, hyperthermia, hypertension, tachycardia, and dystonia.¹ Early identification and management are essential for improving prognosis. Symptoms present in a cyclical/paroxysmal nature, lasting up to months after the initial injury, and along with medical history, can help to differentiate between disorders with similar presentations such as sepsis, NMS, thyroid storm, etc.² Management includes supportive care and medications that counteract sympathetic hyperactivity such as Beta blockers, Clonidine, Dantrolene, Opioids, Gabapentin, Benzodiazepines, and Dopamine agonists.¹

Conclusions: Early recognition and interventions are essential for management of PAID syndrome. Awareness of cases increases understanding, improves patient outcomes, and lowers utilization of healthcare resources in acute care.³