Treatment of a resistant Neurogenic fever after ischemic stroke: a report

Dr L. G. Giaccari at Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy and colleagues have reported a case of Neurogenic fever after ischemic stroke resistant to conventional therapy with Acetaminophen. The case has appeared in the Journal of Medical Case Reports.

Elevation in body temperature within the first 24 hours of ischemic stroke is fairly common and known to be associated with worse outcomes. Only after thoroughly ruling out infection and the noninfectious etiologies and in the appropriate clinical setting should the diagnosis of central fever be made. Acetaminophen and nonsteroidal anti-inflammatory drugs are typical therapeutic options. External cooling is frequently used when pharmacologic interventions are inadequate.

A 70-year-old Caucasian woman arrived at the emergency department of a local hospital a few hours after a sudden loss of consciousness. Her medical history included type 2 diabetes mellitus being treated with oral hypoglycemic agents and insulin, untreated chronic atrial fibrillation, and transient ischemic attack about 10 years earlier.

On the basis of suspicion of stroke, computed tomographic angiography was performed, which revealed evidence of right middle cerebral artery (MCA) occlusion. Being within 6 hours of stroke onset, intra-arterial thrombectomy was performed, which did not resolve the occlusion. After 7 days of apparent clinical improvement, the patient had a rapid deterioration of the state of consciousness with acute respiratory failure, for which she was intubated, mechanically ventilated, and transferred to our intensive care unit (ICU).

At the time of admission, the patient presented with a state of neurological deterioration (Glasgow Coma Scale [GCS] score, 3) and a body temperature of 39 °C. Blood and urine tests, infection investigations, and chest x-ray were performed. Blood tests showed the absence of leukocytosis and negative C-reactive protein (CRP), whereas procalcitonin was not available at the time of admission to the ICU. Tests for urinary, pulmonary, and bloodstream infections required 48 hours for results. No abnormalities were observed on the chest x-ray. Tailored antibiotic treatment was initiated on the basis of suspicion of late-onset hospital-acquired pneumonia with piperacillin/tazobactam 4.5 g intravenously every 6 hours and linezolid 600 mg intravenously every 12 hours. The patient's fever was treated with acetaminophen 1000 mg up to four times per day, which produced a nonsignificant reduction in body temperature. Brain computed tomography (CT) was performed, which confirmed the presence of an ischemic lesion of the right MCA with involvement of the structures of the right cerebral hemisphere.

The results of blood, urine, and infection investigations, including bronchial aspirate, were negative, as was the procalcitonin test. Chest x-ray and lung CT did not show signs of infection.