Fatal fever of unknown origin in acute cervical spinal cord injury: five cases

Unraveling quad fever: Severe hyperthermia after traumatic cervical spinal cord injury

PURPOSE

There are many infectious and inflammatory causes for elevated core-body temperatures, though they rarely pass 40 ℃ (104 ℉). The term "quad fever" is used for extreme hyperpyrexia in the setting of acute cervical spinal cord injuries (SCIs). The traditional methods of treating hyperpyrexia are often ineffective and reported morbidity and mortality rates approach 100%. This study aims to identify the incidence of elevated temperatures in SCIs at our institution and assess the effectiveness of using a non-invasive dry water temperature management system as a treatment modality with mortality.

METHODS

A retrospective analysis of acute SCI patients requiring surgical intensive care unit admission who experienced fevers ≥ 40 ℃ (104 ℉) were compared to patients with maximum temperatures < 40 ℃. Patients ≥18 years old who sustained an acute traumatic SCI were included in this study. Patients who expired in the emergency department; had a SCI without radiologic abnormality; had neuropraxia; were admitted to any location other than the surgical intensive care unit; or had positive blood cultures were excluded. SAS 9.4 was used to conduct statistical analysis.

RESULTS

Over the 9-year study period, 35 patients were admitted to the surgical intensive care unit with a verified SCI. Seven patients experienced maximum temperatures of ≥ 40 ℃. Six of those patients were treated with the dry water temperature management system with an overall mortality of 57.1% in this subgroup. The mortality rate for the 28 patients who experienced a maximum temperature of ≤ 40 ℃ was 21.4% (p = 0.16).

CONCLUSION

The diagnosis of quad fever should be considered in patients with cervical SCI in the presence of hyperthermia. In this study, there was no significant difference in mortality between quad fever patients treated with a dry water temperature management system versus SCI patients without quad fever. The early use of a dry water temperature management system appears to decrease the mortality rate of quad fever.

Quad Fever in a Case of Cervical Cord Injury—A Rare Case Report

By definition, “quad fever” is an extreme elevation in body core temperature beyond 40.8°C (105.4°F) in a patient with spinal cord injury. This type of central nervous system hyperpyrexia is seen in spinal cord injury patients, particularly those with high cervical spine injury with quadriplegia. However, it has also been described in paraplegics with a mid- or higher level thoracic spine injury. The incidence of “quad fever” is rare, with the highest reported temperature being 44°C (111.2°F) with chronicled fatal outcomes.

Though the use of antipyretics is generally efficacious, they are considerably ineffective in treating the hyperpyrexia seen in this type of severe central autonomic thermodysregulation.

Here, we present a case of high cervical spine injury in a 24-year-old male. The trauma resulted in a C3–5 level cord contusion with incomplete quadriplegia (ASIA [American Spinal Cord Injury Association Impairment Scale] grade B). The patient developed high grade fever of 106°F within a week of admission postoperatively.

Pancultures were negative and the wound was clean. Despite treatment with higher antibiotics and an infection disease specialist's consult, no obvious etiology was found. Drug-induced fever and thyroid function tests were excluded in other less-common causes.

Based on the diagnosis of exclusion, “quad fever” was inferred as the cause. He had other signs of autonomic instability during the episodes such as bradycardia with hypotension.

Our patient showed an almost early response to treatment to betablockers and antipsychotics after failure to respond to antibiotics, mechanical hypothermia, and antipyretics.

Spinal cord injury-related thermoregulatory impairment masks a fatal malignant hyperthermia crisis: a case report

PURPOSE

Malignant hyperthermia (MH) is a hypermetabolic disorder that can occur in genetically susceptible individuals exposed to halogenated anesthetics and succinylcholine. Spinal cord injury (SCI) above the sixth thoracic vertebra is associated with dysfunction of the sympathetic/parasympathetic nervous pathways, including thermoregulatory dysfunction, presenting as hypothermia in cold environments because of vasodilation and heat loss. This effect could mitigate or obscure an MH episode. Here, we describe development of a fatal MH crisis in a patient with SCI.

CLINICAL FEATURES

A 27-yr-old male patient with an SCI after fracture of the sixth cervical vertebra was admitted for spinal arthrodesis. Anesthetic medications included remifentanil, propofol, succinylcholine, rocuronium, and isoflurane. After the start of the surgery, muscular contractures resembling myoclonus were noted, which resolved with pancuronium administration. Four hours after the start of anesthesia, the patient presented with hyperthermia, hypercarbia, hypotension, muscle rigidity, arrhythmia, and cardiogenic shock, with metabolic/respiratory acidosis. Malignant hyperthermia was suspected and the treatment was started, but he developed cardiopulmonary arrest and died an hour and a half after the first cardiac arrest. Both parents were investigated and were found to have normal creatine kinase levels and positive in vitro contracture tests. His mother carried a variant in the ryanodine receptor type 1 (RYR1) gene (c.14918C>T), which is associated with MH.

CONCLUSION

Spinal cord injury-induced thermoregulatory dysfunction may obscure the early diagnosis of MH and lead to fatal outcome.

Non-infectious Fever After Acute Spinal Cord Injury in the Intensive Care Unit

OBJECTIVE

The aim of the present study is to evaluate the frequency, etiology, risk factors and clinical outcomes in acute traumatic SCI patients who develop fever and to evaluate the relationship between fever and mortality.

DESIGN

Retrospective data were collected between January 2007 and August 2016 from patients diagnosed with persistent fever from SCI cases observed in the ICU.

PARTICIPANTS

Among 5370 intensive care patients, 435 SCI patients were evaluated for the presence of fever. A total of 52 patients meeting the criteria were evaluated.

OUTCOME MEASURES

Fever characteristics were evaluated by dividing the patients into two groups: infectious (group-1) and non-infectious (group-2) fever. Demographic and clinical data, ICU and hospital stay, and mortality were evaluated.

RESULTS

In the patients with noninfectious fever, mortality was significantly higher compared to the group with infectious fever (P < 0.001). Of 52 acute SCI cases, 25 (48.1%) had neurogenic fever that did not respond to treatment in intensive care follow-up, and 22 (88%) of these patients died. Maximal fever was 39.10 ± 0.64 °C in Group-1 and 40.22 ± 1.10 ° C in Group-2 (P = 0.001). There was a significant difference in the duration of ICU stay and hospital stay between the two groups (P = 0.005, P = 0.001, respectively), while there was no difference in the duration of mechanical ventilation between the groups (P = 0.544).

CONCLUSION

This study demonstrates that patients diagnosed with neurogenic fever following SCI had higher average body temperature and higher rates of mortality compared to patients diagnosed with infectious fever.

Quad Fever: Treatment through Lowering of Ambient Temperature

Hyperpyrexia is a rare and at times fatal condition seen in an Intensive Care Unit setup. We encountered a case of a 65-year-old patient with road traffic accident presenting with dorsal spine fracture at D₁₀ level. He underwent decompression and fusion for the same. He developed hyperpyrexia of sudden onset on the 10^th day of admission with no source of infection and adequate broad-spectrum antibiotic coverage with adequate thrombo-embolic prevention in place. The patient showed no response to antipyretic agents and other cooling methods. The origin of hyperthermia was idiopathic, and we speculate that the cause was secondary to hyperthermic thermoregulatory dysfunction often quoted as “quad fever,” seen in spinal cord injury. We present a brief review of literature and the importance of early identification and treatment of this potentially fatal condition.

Pure distraction injury of T1-2 with quad fever

INTRODUCTION

We report a pure distraction injury of the upper thoracic spine and uncontrolled hyperthermia without an infectious cause. Quad fever appears in the first several weeks to months after a cervical or upper thoracic SCI and is characterized by an extreme elevation in body core temperature beyond 40 °C without an infectious cause. Discriminating between infectious and noninfectious causes is important, and a thorough clinical assessment is required.

MATERIALS AND METHODS

A 52-year-old male visited the emergency room complaining of back pain with complete paralysis [American Spinal Injury Association (ASIA) A] of both lower extremities after a pedestrian-motor vehicle accident. He had trouble breathing due to a hemothorax and flail chest caused by fractures of the right second to eleventh and left fourth to seventh ribs. A computed tomography scan revealed severe distraction of the T1-2 intervertebral space. A magnetic resonance image showed signal changes in the spinal cord and a clean-cut margin between the T1-2 disc and T2 body. The neurological level of injury was C8 upon the initial neurological assessment. Emergency surgery was performed. C6-T3 posterior instrumentation and an autologous iliac bone graft were performed.

RESULTS

After surgery, the core temperature increased gradually to above 38.0 °C on post-trauma day 4 and increased to 40.8 °C on post-trauma day 7. None of the repeated aerobic, anaerobic, or fungal cultures of the blood, tracheal aspirate, line tips, urine, or stool was positive until post-trauma day 21, when Candida tropicalis was identified in the urine culture. On post-trauma day 63, the blood pressure, pulse, and body temperature stabilized and the patient was transferred to the general ward. At post-trauma year 6, the injury state was still complete and the neurological level of injury was changed to C4.

CONCLUSIONS

Based on the Grand Round case and relevant literature, we discuss the case of pure distraction injury of T1-2 with quad fever. Spinal surgeons should be knowledgeable regarding quad fever as well as the differential diagnoses and treatment strategies.

QUAD fever: beware of non-infectious fever in high spinal cord injuries

A case of cervical spinal cord injury and quadriparesis with prolonged fever is being described. Initially, the patient received treatment for well-documented catheter-related bloodstream infection. High spiking fever returned and persisted with no obvious evidence of infection. The usual non-infectious causes too were carefully excluded. QUAD fever or fever due to spinal cord injury itself was considered. The pathogenetic basis of QUAD fever is unclear but could be attributed to autonomic dysfunction and temperature dysregulation. Awareness of this little known condition could help in avoiding unnecessary antimicrobial therapy and in more accurate prognostication. Unlike several previous reported cases that ended fatally, the present case ran a relatively benign course. The spectrum of presentations may therefore be broader than hitherto appreciated.

Neurogenic Fever after Acute Traumatic Spinal Cord Injury: A Qualitative Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

To determine the incidence, pathogenesis, and clinical outcomes related to neurogenic fevers following traumatic spinal cord injury (SCI).

METHODS

A systematic review of the literature was performed on thermodysregulation secondary to acute traumatic SCI in adult patients. A literature search was performed using PubMed (MEDLINE), Cochrane Central Register of Controlled Trials, and Scopus. Using strict inclusion and exclusion criteria, seven relevant articles were obtained.

RESULTS

The incidence of fever of all origins (both known and unknown) after SCI ranged from 22.5 to 71.7% with a mean incidence of 50.6% and a median incidence of 50.0%. The incidence of fever of unknown origin (neurogenic fever) ranged from 2.6 to 27.8% with a mean incidence of 8.0% and a median incidence of 4.7%. Cervical and thoracic spinal injuries were more commonly associated with fever than lumbar injuries. In addition, complete injuries had a higher incidence of fever than incomplete injuries. The pathogenesis of neurogenic fever after acute SCI is not thoroughly understood.

CONCLUSION

Neurogenic fevers are relatively common following an acute SCI; however, there is little in the scientific literature to help physicians prevent or treat this condition. The paucity of research underscored by this review demonstrates the need for further studies with larger sample sizes, focusing on incidence rate, clinical outcomes, and pathogenesis of neurogenic fever following acute traumatic SCI.

Acute non-ambulatory tetraparesis with absence of the dens in two large breed dogs: case reports with a radiographic study of relatives

Background

Non-ambulatory tetraparesis with an absence of the dens of C2 (axis) has not previously been reported in large breed dogs. An absence or hypoplasia of the dens has been reported in both small, medium and large breed dogs, but not in closely related animals.

Methods

Two young large-breed dogs (a German shepherd and a Standard poodle) both with an acute onset of non-ambulatory tetraparesis were subjected to physical, neurological and radiographic examinations. Both dogs were euthanased and submitted for postmortem examination within one week of onset of clinical signs. To investigate possible heritability of dens abnormalities, oblique radiographs of the cranial cervical vertebrae were taken of nine and eighteen dogs related to the German shepherd and the Standard poodle, respectively.

Results

Absence of the dens, atlantoaxial instability and extensive spinal cord injury was found in both case dogs. Radiographs revealed a normal dens in both parents and in the seven littermates of the German shepherd. An absence or hypoplasia of the dens was diagnosed in six relatives of the Standard poodle.

Conclusions

Atlantoaxial subluxation with cervical spinal cord injury should be considered as a differential diagnosis in non-ambulatory tetraparetic young large breed dogs. Absence of the dens and no history of external trauma increase the likelihood for this diagnosis. This study provides evidence to suggest that absence or hypoplasia of the dens is inherited in an autosomal way in Standard poodle dogs.

Endovascular cooling for severe hyperthermia in cervical spine injury

BACKGROUND

Sustained severe hyperthermia in patients with high cervical spinal cord injuries may have many etiologies, from infection to autonomic dysregulation. When uncontrolled, it has been seen to have a high morbidity and mortality.

METHODS

We present two patients with high cervical spinal cord injury (SCI) who had sustained severe hyperpyrexia, of possible autonomic origin. The temperature stayed above 40°C and was uncontrolled with conventional methods of temperature management.

RESULTS

We employed endovascular cooling for therapeutic normothermia which was successful in effective control of temperature in both the patients. The first patient suffered complications from deep vein thrombosis and pulmonary embolism which may be attributed to the presence of the cooling catheter in spite of chemical and mechanical thromboprophylaxis.

CONCLUSIONS

The use of endovascular cooling in the management of severe life threatening hyperthermia in patients with cervical SCI may be an useful intervention. There must be a high suspicion for the possibility of deep vein thrombosis in this subgroup, however.

Malignant Hyperpyrexia in Cervical Spine Injury

Pyrexia is an elevation of body temperature above the normal range due to an increase in the hypothalamic thermoregulatory set point. Hyperpyrexia is an extreme elevation of body temperature equal to or greater than 41.5°C (106.7°F). (1) Malignant hyperpyrexia is a rare and idiopathic extreme elevation of core body temperature above 42°C characterized by the acute onset of hyperthermia, coagulopathy and shock. (2) It is potentially life-threatening and can rapidly progress to severe liver and renal impairment, acidosis and encephalopathy. Reported here is a case of malignant hyperpyrexia in a patient with injury of the cervical spine.