Disclosures: Kavita Nadendla, MD: No financial relationships or conflicts of interest

Case Diagnosis: A 12-year-old boy with spastic quadriplegic cerebral palsy (CP), Lennox-Gastaut syndrome secondary to infantile HSV encephalitis, chronic respiratory failure with tracheostomy and ventilator dependence, neurogenic bowel and bladder, and history of autonomic dysfunction.

Case Description: The patient underwent a posterior spinal fusion for neuromuscular scoliosis. On post-operative day (POD) 3, he experienced a prolonged episode of hypothermia, hypotension, decreased muscle tone, and relative unresponsiveness lasting 36 hours. Two additional episodes were reported on POD6 lasting 20 minutes and POD10 lasting 4 hours. A comprehensive workup was performed. Infectious work-up was negative, baclofen pump malfunction and seizures were ruled out, and there were no metabolic abnormalities. MRI brain showed no new findings. During the episodes, supportive care was provided including warming blanket, pain management, and identification and avoidance of triggers. He was continued on clonidine and gabapentin to help promote autonomic regulation.

Setting: Acute care tertiary pediatric hospitalAssessment/

Results: At 2 weeks post-operative, he had no further episodes of autonomic instability and was admitted to inpatient rehabilitation. Worsened autonomic instability was felt to be a result of physiologic stress from surgery.

Discussion: Although paroxysmal sympathetic hyperactivity has been described after severe acquired brain injury, scant literature exists on autonomic dysfunction in patients with CP. In this case, it was unclear if the etiology of these episodes was due to overactivation of the parasympathetic system or loss of sympathetic activity. This is the first reported case, to our knowledge, of paroxysmal episodes of hypothermia, bradycardia, hypotension, flaccidity, and relative unresponsiveness in a child with CP.

Conclusion: In patients with CP, early recognition of dysautonomia in conjunction with multimodal treatment of environmental modification and appropriate pharmacologic therapy is important to help shorten inpatient stays and improve patient outcomes.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/worsening-autonomic-instability-in-a-child-with-cerebral-palsy-a-case-report/