CASE PRESENTATION
A 27-year-old male arrived at the emergency department following a road
traffic accident involving a collision with a four-wheeler while riding
a bike. Initial medical attention was provided at a local hospital,
where endotracheal intubation was performed due to a low Glasgow Coma
Scale (GCS). Subsequently, he was referred to our center for advanced
care.
Upon presentation, his vital signs were as follows: blood pressure
130/80mmHg, heart rate 116 beats/min, temperature 38°C, and respiratory
rate 24 breaths/min under controlled mechanical ventilation. His Spo2
was 97% on fio2 of 90%. The GCS score was 5/15.
A magnetic resonance imaging (MRI) scan revealed diffuse axonal injury
with pontine hemorrhage and subdural hematoma (figure 1). He received
conservative management to control intracranial pressure, prophylactic
antibiotics, antiepileptic medication (Levetiracetam), and other
supportive treatments. Mean arterial pressure (MAP) was targeted to
maintain cerebral perfusion pressure above 60 mmHg.
Laboratory results indicate leukocytosis with a total white cell count
of 20,300 Cells/Cumm.
On the third day of ICU admission, the patient developed a continuous
fever. Initial culture reports and a new set of laboratory tests (CBC,
ESR, CRP, and Procalcitonin) all returned negative for infections. A
chest x-ray was performed to rule out ventilator-associated pneumonia,
but no definitive cause for the fever could be identified.
Antipyretics and surface cooling measures were initiated, and empiric
antibiotic therapy was upgraded to intravenous meropenem and
polymyxin-B. Despite these efforts, the patient remained hyperpyretic
(figure 2).
On the seventh day of ICU admission, repeat cultures were taken, and
procalcitonin levels remained low, yet the patient’s clinical condition
did not improve. Antimicrobials were further upgraded to intravenous
tigecycline, and antifungal medication (caspofungin) was added.
Echocardiography ruled out infective endocarditis, and a review of
medications found no evidence of drug fever.
By the fourteenth day of ICU admission, with all infectious causes
excluded, a diagnosis of central hyperpyrexia was established.
Neuroleptic malignant syndrome too was excluded as other clinical
features suggestive of the same were absent.
Following a thorough literature review, oral baclofen (10 mg Q8H) and
propranolol (20 mg Q12H) were introduced. After 48 hours, the patient’s
temperature decreased to 38°C, occasionally spiking to 38.5 - 39°C. The
doses of both medications were increased to; Baclofen 20 mg Q8H and
Propranolol 20 mg Q8H.
After 10 days of treatment with Baclofen and Propranolol, the patient’s
temperature and heart rate returned to normal (figure 3). Both
medications were continued for an additional 4 days and then stopped, as
the temperature and heart rate remained stable with no recurrence of
fever. The patient was subsequently transferred to the ward.