What is the treatment approach for a patient presenting with fever and neurological symptoms including spasms?

Management of Fever with Neurological Symptoms and Spasms

A patient presenting with fever and neurological symptoms including spasms requires immediate assessment for acute encephalitis or central nervous system infection, with urgent neurological specialist consultation within 24 hours and empiric treatment initiation before diagnostic confirmation if clinically indicated. 1

Immediate Assessment and Stabilization

Airway and Consciousness Evaluation

• Patients with falling level of consciousness require urgent ICU assessment for airway protection, ventilatory support, and management of raised intracranial pressure 1
• Equipment necessary to maintain a patent airway and support respiration/ventilation should be immediately available, as heavily sedated patients are at risk for airway obstruction 2
• Monitor oxygen saturation continuously with a target of ≥92%, administering supplemental oxygen if hypoxia is detected 3

Seizure Management

• For active seizures (status epilepticus), administer lorazepam 4 mg IV slowly (2 mg/min) for patients ≥18 years 2
• If seizures continue or recur after 10-15 minutes observation, give an additional 4 mg IV dose slowly 2
• Maintain IV access, monitor vital signs, ensure unobstructed airway, and have artificial ventilation equipment available 2
• Consider concomitant IV phenytoin administration as part of comprehensive status epilepticus management 2

Diagnostic Workup Priority

Neuroimaging

• Obtain MRI within 48 hours as the imaging modality of choice, detecting early cerebral changes in approximately 90% of cases versus only 25% for CT 1
• If MRI unavailable or contraindicated (implantable cardiac devices, claustrophobia), obtain CT scan to exclude space-occupying lesions or obstructive hydrocephalus 1, 4

Cerebrospinal Fluid Analysis

• Perform lumbar puncture if no contraindications exist (no papilledema, no mass effect on imaging) 1, 4
• CSF PCR results should ideally be available within 24-48 hours of lumbar puncture 1
• Send CSF for bacterial (aerobic and anaerobic) cultures, viral PCR panel, cell count, protein, and glucose 3

Blood Work

• Obtain at least two sets of blood cultures (60 mL total) before antibiotic administration 5
• Check complete blood count, comprehensive metabolic panel, ESR, and CRP 3
• For returned travelers from malaria-endemic areas, obtain rapid blood malaria antigen tests and three thick and thin blood films 1
• Correct any metabolic derangements immediately (hypoglycemia, hyponatremia) as these can precipitate seizures 2

Additional Testing

• Obtain EEG when distinguishing psychiatric versus organic causes or when subtle motor or non-convulsive seizures are suspected 1
• Chest radiograph for all febrile patients to evaluate for pneumonia or aspiration 5

Temperature Management

Aggressive Fever Control

• Fever should be aggressively treated to normal levels (36.0-37.5°C) with antipyretic medications, as fever is independently associated with poor neurological outcomes and can precipitate secondary brain injury 4, 5
• Administer acetaminophen as first-line antipyretic agent immediately when temperature reaches 37.5°C 4, 5
• Do not delay antipyretic treatment while searching for fever source, as fever duration correlates with worse outcomes 5
• Use automated feedback-controlled temperature management devices for severe cases with refractory fever 4, 5

Temperature Monitoring

• Use central temperature monitoring when available (bladder catheter, esophageal thermistor, or pulmonary artery catheter) for accurate measurement 5
• Continuous monitoring is preferable to intermittent measurements 5
• Maintain temperature with minimal variation (≤±0.5°C per hour, ≤1°C per 24 hours) 5

Empiric Treatment Considerations

When to Initiate Treatment Before Diagnosis

• If cerebral malaria seems likely and there will be delay in obtaining malaria film results, initiate anti-malarial treatment immediately and obtain specialist advice 1
• For suspected bacterial meningitis with fever and neurological symptoms, do not delay antibiotics while awaiting lumbar puncture if contraindications exist 3

Etiology-Specific Treatment

Cerebral Malaria (Plasmodium falciparum):

• Administer quinine, quinidine, or artemether 1
• Exchange transfusion recommended for ≥10% parasitemia 1
• Corticosteroids are NOT recommended 1

Toxoplasma gondii:

• Treat with pyrimethamine plus either sulfadiazine or clindamycin 1

Acute Disseminated Encephalomyelitis (ADEM):

• High-dose corticosteroids as first-line treatment 1
• Alternatives include plasma exchange or intravenous immunoglobulin 1

Critical Pitfalls to Avoid

Neurogenic Fever Considerations

• Neurogenic fever occurs in approximately 25% of neurocritical patients, with nearly half being non-infectious in origin 4
• Non-infectious fever is more common in subarachnoid hemorrhage (48% vs 18% infectious) and associated with vasospasm 6
• Fever onset within first 72 hours of admission predicts non-infectious cause 6
• However, always investigate all potential infectious sources before attributing fever to central causes, as patients with neurological injury are immunocompromised and predisposed to sepsis 4, 5

Delayed Diagnosis Risks

• Malaria imported to non-endemic settings is sometimes initially overlooked, and delayed diagnosis is responsible for preventable deaths annually 3
• Suspect native vertebral osteomyelitis in patients with fever and new neurological symptoms with or without back pain 3

Disposition and Follow-up

• Manage patients in appropriate settings including neurological wards, high dependency units, or intensive care units depending on severity 1
• All patients should have access to assessment for rehabilitation, as sequelae may not be immediately apparent at discharge 1
• Do not discharge without either a definite or suspected diagnosis, with arrangements for outpatient follow-up and plans for ongoing therapy formulated at discharge meeting 1