Managing Fever and Central Temperature Regulation After Brain Injury

Fever of unknown origin, central fever?

Hello, my father suffered a subarachnoid hemorrhage at the beginning of this year, which led to hydrocephalus.
He immediately had an external ventricular drain placed to manage the cerebrospinal fluid.
After a cerebral angiogram revealed an aneurysm, he underwent surgery to remove it the same day.
He developed a fever a few days post-operation and was treated with antibiotics, but then a fungal infection was discovered in the drainage tube.

Ten days later, the cerebrospinal fluid drainage was minimal, and he had not regained consciousness.
A CT scan was performed, and the doctor recommended placing a permanent ventriculoperitoneal shunt.
After a successful surgery, he gradually regained consciousness, but a few days later, he developed a fever again and continued antibiotic treatment for nearly two weeks, with another fever occurring just before the treatment ended.
Throughout this process, bacterial cultures yielded no results, and the cerebrospinal fluid was normal, with fever subsiding in the initial days.
However, a month later, he would develop a fever with every hiccup, and five days later, he became disoriented.
Tests revealed cloudy cerebrospinal fluid, leading to the conclusion that the ventriculoperitoneal shunt had become infected, necessitating its urgent removal and replacement with an external drainage tube for two weeks.
He subsequently developed meningitis and sepsis, with bacterial cultures confirming the presence of Gram-negative bacteria: Escherichia coli.
He continued antibiotic treatment and regained consciousness ten days later, able to converse, with a maximum of five days without fever.
After two weeks of stability, he was moved out of the ICU, but three days later, he developed a fever again.
The external drainage tube was replaced, but the fever persisted, often fluctuating from 36.5 degrees Celsius to over 38 degrees Celsius within an hour, accompanied by rapid breathing and increased heart rate.
He was readmitted to the ICU for observation for two weeks.
Currently, tests show no inflammation in the heart or lungs, and inflammatory markers have decreased, but he has yet to regain consciousness, only opening his eyes and moving his limbs slightly.
The physician has determined that the brain injury is affecting the thermoregulatory center, and since the parameters are normal, they recommend discharge to manage his temperature with antipyretics at home.
Is this really the only way to manage his condition? Are there no additional examinations needed for the brain injury? Besides infectious disease and neurosurgery, are there other specialties that could assist in this situation?

Niming, 30~39 year old female. Ask Date: 2021/05/13

Dr. Lin Wufu reply Internal Medicine

Hello! Your father's condition is quite complex, making it difficult to assess based solely on your brief description.
The diagnosis of central fever is made only after excluding other infectious causes, and it can be established only when laboratory tests show no obvious signs of infection.
Therefore, it is likely that a thorough examination was conducted during his hospitalization.
To determine if there are any "additional tests" that can be performed, it is essential to know what tests your father has already undergone.
It is recommended to continue follow-up care at the original hospital, as the follow-up process may help identify the exact cause of the fever.
I hope this information is helpful to you.

Reply Date: 2021/05/13

More Info

Managing fever and central temperature regulation after a brain injury is a complex issue that requires a multidisciplinary approach. In your father's case, the history of subarachnoid hemorrhage, subsequent hydrocephalus, and the complications arising from the external drainage system highlight the intricacies involved in post-operative care for neurological patients.
Fever in patients with brain injuries can be attributed to several factors, including infections, inflammation, and central thermoregulatory dysfunction. In your father's situation, the recurrent fevers, despite the absence of identifiable infections in cultures and normal cerebrospinal fluid (CSF) analysis, suggest that central fever may be a significant contributor. Central fever occurs when the hypothalamus, the brain's temperature regulation center, is affected by injury or inflammation, leading to dysregulation of body temperature.

The management of fever in such cases is crucial, as elevated body temperature can exacerbate neurological damage and hinder recovery. In your father's case, the use of antipyretics (fever-reducing medications) is appropriate, especially since he has shown a pattern of fever that correlates with certain activities, such as hiccups. This could indicate a central mechanism rather than a peripheral infection.
In terms of additional evaluations, while it seems that extensive testing has already been conducted, it may be beneficial to consider further imaging studies, such as MRI, to assess for any structural changes or complications that might not have been evident on previous scans. Consulting with other specialties, such as neurology, rehabilitation medicine, and infectious disease specialists, could provide a more comprehensive understanding of your father's condition and help tailor a more effective management plan.

Rehabilitation specialists can play a vital role in the recovery process, especially if there are concerns about neurological deficits or the potential for long-term disability. They can assist in developing a rehabilitation plan that addresses both physical and cognitive recovery, which is essential for improving overall function and quality of life.

In summary, while managing fever with antipyretics is a necessary step, it is equally important to continue monitoring your father's neurological status and consider further evaluations to rule out any underlying issues. Engaging a multidisciplinary team will provide a more holistic approach to his care, potentially improving outcomes and addressing the complexities of his condition.

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