(Kiosk 3) “quad Fever?” Multiorgan Failure Including Brain Injury Following a High Cervical SCI

Case Diagnosis: Hyperpyrexia in the setting of recent SCI.

Case Description: The patient initially presented with rapidly progressing weakness in all extremities and anesthesia below the C6 dermatome. In the ED, she was found to have retropharyngeal abscess from C2-C7 on CT, presumed to be secondary to previous drug injection.

The next day, she underwent C3-C7 laminectomy for drainage of the abscess followed by C2-T2 posterior spinal instrumentation and fusion. She was found to have a C2 AIS A SCI. Her stay was complicated by mediastinal abscess extension, MRSA bacteremia and endocarditis. She subsequently underwent mediastinal debridement, and her condition stabilized.

However, two weeks later her neurological condition abruptly worsened in the setting of fever to 107.6°F; the patient lost all brainstem reflexes. Her medical workup revealed concern for bilateral symmetric pattern of restricted diffusion most prominent in the globus pallidus bilaterally on MRI Brain. CSF studies were unremarkable, EEG showed no evidence of seizure, and TTE was negative. Labs showed evidence of ischemic hepatitis and acute kidney injury but were otherwise unremarkable. The patient was started on empiric treatment. She received hemodialysis for uremia for 2.5 weeks until it was stopped in the setting of renal recovery.

Discussion: Quad Fever has been described in the literature as fever to >101.5°F in patients with SCI. Although the mechanism is unresolved, it is thought to be related to autonomic dysfunction commonly seen in patients with SCI above T6. Hyperpyrexia to this degree is associated with progressive organ failure.

Setting: Level 1 hospital

Assessment/Results: Approximately one month after her neurological decline, her workup remained otherwise negative. On discharge to a SNF, she was noted to open eyes spontaneously but did not track or respond to noxious stimuli.

Conclusion: Quad fever should be considered in patients with high SCI when workup is not revealing and environmental factors have been ruled out.