An 18-year-old female came to the inpatient ward from her local physician’s office for a diagnosis of febrile urinary tract infection and mild dehydration that was worsening over the past 24 hours. She had strong smelling urine, a low grade fever and was not feeling well. She said she just didn’t want to drink either. Her past medical history showed she had a C7 spinal cord injury at age 16 because of a motor vehicle accident. Her main problems were constipation, repeated urinary tract infections, and some occasional dermatitis. During the first year after her injury she had some bouts of autonomic dysreflexia but this was usually well-controlled. The review of systems was otherwise negative.
The pertinent physical exam showed her lying in bed. Her temperature was 101.3° F with a normal blood pressure. She had generalized muscle wasting. Her abdomen was soft without organomegaly, masses or distension. Her neurological examination showed no feeling or motor movement from the upper thoracic region downward. The laboratory evaluation showed a dirty appearing urine that had a specific gravity of 1.025, was positive for leukocyte esterase, nitrate and blood, and showed 45 white blood cells, and 10 red blood cells. Her complete blood count showed a white blood cell count of 21.2 x 1000/mm2 with a left shift. Her C-reactive protein was 5.6 mg/dl. She was started on empiric antibiotics and her urine culture eventually grew E. coli. She was changed to oral antibiotics based upon the organism’s sensitivities. The patient’s clinical course initially had waxing and waning mild hypertension to 140-150 systolic and 100-110 for diastolic. The hypertension seemed to correspond to the patient being febrile and when her bladder was full. She was treated with more consistent urinary drainage by clean intermittent catheterization and given antipyretics on a scheduled basis. After 4 days she was well hydrated, afebrile, her hypertension had resolved and she was discharged home.
Autonomic dysreflexia (AD) or hyperreflexia occurs in people with spinal cord injuries where the automatic signals and responses within the body problem do not occur normally.
The University of Alabama’s Department of Physical Medicine and Rehabilitation explains it this way: “AD occurs as a response to some type of irritation below the level of injury. The body tries to send signals to the brain to identify and respond to the irritant, but signals are blocked by the [spinal cord injury].” “Without communication between the brain and body, blood vessels begin to narrow and cause a rise in blood pressure. When sensors tell the brain that the blood pressure is getting too high, the brain then tries to lower the blood pressure….”
Causes of AD are usually normal physiological states but in this setting of spinal cord injury are irritants. These include bladder problems such as spasms, or just an overfilled bladder. Bowel problems are similar with constipation being a common irritant. Skin problems including pressure sores, wounds, rashes or just general dermatitis. Other problems include temperature extremes, trauma, pressure on body parts, abdominal cramping, and for women genitourinary states such as menstrual cramping, pregnancy and labor.
Treatment is to find the irritation and eliminate it. Hypertension may need to be treated with anti-hypertensive medication. AD can be a medical emergency.
Additional symptoms may be minimal or none except for hypertension.
Other signs and symptoms of AD include:
- “Pounding headache
- Blurred vision
- Flushed face
- Nasal congestion
- Red blotches on upper body
- Cool, clammy skin
- Chills without fever
- Apprehension or anxiety
- Sweating above the level of injury
- Good bumps above the level of injury
- Slow pulse”
Questions for Further Discussion
1. How can a physical medicine and rehabilitation specialist assist in patients with chronic medical diseases?
2. Besides AD, what other problems are patients with spinal cord disease at risk for?
- Specialty: General Pediatrics | Physical Medicine and Rehabilitation / Physical Therapy | Infectious Diseases
- Age: Teenager
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Krassioukov A, Warburton DE, Teasell R, Eng JJ; Spinal Cord Injury Rehabilitation Evidence Research Team. A systematic review of the management of autonomic dysreflexia after spinal cord injury. Arch Phys Med Rehabil. 2009 Apr;90(4):682-95.
Bice T., Huang CT, Klebine P. University of Alabama Department of Physical Medicine and Rehabilitation. Spinal Cord Injury Infosheet. Available from the Internet at www.spinalcord.uab.edu (rev. 3/2009, cited 9/2/13).
Milligan J, Lee J, McMillan C, Klassen H. Autonomic dysreflexia: recognizing a common serious condition in patients with spinal cord injury. Can Fam Physician. 2012 Aug;58(8):831-5.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital