What management is recommended for a patient with recurring fevers (pyrexia), Arteriovenous Malformation (AVM), and a history of seizures, currently being followed by a Neurologist (neurology provider)?

Management of Recurrent Fevers in a Patient with AVM and Seizure History

You need to conduct an urgent and systematic workup to identify the source of these recurrent high fevers, as they are not explained by the patient's known AVM or seizure disorder and could represent serious underlying pathology including infection, malignancy, or autoinflammatory disease.

Immediate Priority: Fever Workup

The recurrent fevers (up to 103°F, 1-2 times weekly for a year, predominantly evening) require comprehensive investigation, as this pattern is not a typical manifestation of either AVM or seizure disorders 1.

Essential Diagnostic Evaluation

Conduct the following workup systematically:

• Complete blood count with differential - to evaluate for infection, malignancy (leukemia, lymphoma), or inflammatory conditions 2
• Comprehensive metabolic panel - to assess organ function and identify metabolic causes 2
• Inflammatory markers - ESR and CRP to quantify systemic inflammation 2
• Blood cultures - obtain during febrile episodes to rule out bacteremia or endocarditis 2
• Urinalysis and urine culture - to exclude urinary tract infection 2
• Chest radiograph - to evaluate for pulmonary infection or malignancy 2

Consider Additional Testing Based on Initial Results

• Autoimmune serology (ANA, RF, anti-CCP) if inflammatory markers are elevated 2
• Infectious disease workup including tuberculosis testing, HIV, EBV, CMV if initial cultures are negative 2
• Imaging studies (CT chest/abdomen/pelvis) if malignancy is suspected 2
• Referral to infectious disease or rheumatology if autoinflammatory disease is suspected, particularly given the prolonged duration and evening predominance pattern 2

AVM-Specific Considerations

Hemorrhage Risk Assessment

The AVM itself requires ongoing monitoring but is unlikely the direct cause of fevers:

• AVMs carry a 2-3% annual hemorrhage risk in previously unruptured lesions 1
• The lifetime hemorrhage risk can be estimated as: 105 minus the patient's age in years 1
• Mortality from first hemorrhage ranges from 10-30%, with 10-20% of survivors experiencing long-term disability 1

Fever and AVM Relationship

Important caveat: While fevers are not a typical presentation of AVMs (which usually present with hemorrhage in >50% of cases, seizures in 20-25%, or headaches in 15%), you must ensure the fever is not related to:

• Intracranial infection - particularly if there's any history of prior neurosurgical intervention 1
• Recent hemorrhage - though this would typically present acutely, not with chronic recurrent fevers 1

Seizure Management Coordination

Current Seizure Control

Coordinate with the neurologist regarding:

• Whether current seizure control is adequate, as AVMs presenting with seizures can be challenging to manage 1
• Surgical resection of AVMs has shown 83% seizure freedom rates in patients who presented with seizures, with 48% able to discontinue anticonvulsants 1
• The patient's AVM location and characteristics, as cortical location, size >3 cm, and superficial venous drainage are associated with seizure presentation 3

Febrile Seizure Considerations

Critical distinction: If the patient is a child (age not specified), distinguish between:

• Febrile seizures - which occur in children 6-60 months with fever, lasting <15 minutes (simple) or >15 minutes/focal/recurrent in 24 hours (complex) 4, 5
• AVM-related seizures - which are independent of fever and related to the structural lesion 1

However, the pattern described (recurrent fevers over a year) does NOT fit typical febrile seizure patterns, which are acute events associated with acute febrile illnesses 4, 5.

Coordination of Care

Communication with Neurology

Do not wait for the scheduled appointment in "a few months":

• Contact the neurologist now to discuss the fever pattern and ensure it's not related to AVM complications 1
• Inquire about any recent changes in seizure frequency or character that might suggest AVM progression 1
• Discuss whether accelerated imaging (MRI with and without contrast) is warranted to evaluate the AVM 1

When to Escalate Urgently

Send to emergency department immediately if:

• Fever accompanied by severe headache, altered mental status, or focal neurological deficits (suggesting hemorrhage or infection) 1
• Seizure lasting >5 minutes or repeated seizures without return to baseline 4
• Signs of meningitis (neck stiffness, photophobia, altered consciousness) 1

Common Pitfalls to Avoid

• Do not attribute chronic recurrent fevers to the AVM or seizure disorder - these conditions do not typically cause this fever pattern 1, 2
• Do not delay workup - a year of recurrent high fevers requires investigation regardless of other diagnoses 2
• Do not assume febrile seizures - if this is an adult or older child with known AVM, the seizures are structural, not febrile 1, 4, 5
• Do not wait for the neurology appointment - fever workup is within primary care scope and should begin immediately 2