What is the management approach for a 19-year-old patient with cerebral palsy (CP) who develops abnormal movements of both limbs and face following a fever?

Management of New-Onset Abnormal Movements Post-Fever in a 19-Year-Old with Cerebral Palsy

This patient requires urgent neuroimaging (brain and spinal cord MRI) to exclude acute stroke, hemorrhage, hydrocephalus, or new structural lesions, as cerebral palsy is non-progressive by definition and any sudden neurological deterioration is inconsistent with its natural history. 1

Immediate Diagnostic Workup

Urgent Neuroimaging

• Brain and spinal cord MRI must be obtained emergently to rule out acute stroke, hemorrhage, spinal cord compression, hydrocephalus, and new structural lesions 1
• Never assume new symptoms are "just the cerebral palsy"—CP is defined as a non-progressive disorder, and sudden changes mandate investigation for alternative pathology 1
• Delaying neuroimaging is dangerous as acute stroke or spinal cord pathology requires time-sensitive intervention 1

Concurrent Infectious Workup

• Obtain urinalysis and urine culture immediately to assess for urinary tract infection (UTI), which occurs in 15-60% of patients with neurological conditions and can cause acute changes in level of consciousness and neurological deterioration 1
• Fever preceding the abnormal movements makes infection a critical consideration 1

Additional Assessments

• Evaluate for other infectious triggers including meningitis/encephalitis given the post-fever presentation 1
• Assess for constipation and pressure ulcers as potential triggers 1

Understanding the Clinical Context

Why This Presentation is Concerning

• Spasticity affects 85-91% of CP patients but is established early and does not suddenly worsen without cause 1
• The American Academy of Pediatrics recommends investigation for alternative pathology when there is sudden onset of new neurological symptoms in CP patients 1
• Loss of motor milestones or new abnormal movements suggests a neurodegenerative process or acute neurological event, not CP progression 2

Differential Considerations

• Acute stroke or hemorrhage 1
• Post-infectious movement disorder (e.g., acute disseminated encephalomyelitis, autoimmune encephalitis) 1
• Infection-triggered exacerbation requiring treatment of underlying cause 1
• Spinal cord pathology 1

Management Algorithm After Diagnosis

If Imaging and Workup Are Negative

• Treat underlying triggers first: UTI, constipation, pressure ulcers 1
• Initiate physical therapy with range-of-motion exercises 1
• Consider spasticity management only after acute pathology has been excluded 1

If Acute Pathology Is Identified

• Manage according to specific findings (stroke protocols, neurosurgical intervention for structural lesions, antimicrobial therapy for infections) 1
• Urgent neurology consultation is essential for specialized management 2

Critical Pitfalls to Avoid

• Do not attribute new symptoms to baseline CP without thorough investigation—this violates the fundamental definition of CP as non-progressive 1, 3
• Do not delay neuroimaging while pursuing other diagnostic tests 1
• Do not start spasticity treatments (such as oral baclofen) before excluding acute pathology, as this may mask evolving neurological signs 1
• Do not assume the fever is unrelated—post-infectious neurological complications must be considered 1

Specialist Referral

• Immediate neurology consultation is warranted for new neurological deterioration in a CP patient, as early diagnosis and intervention improves outcomes through specialized expertise 2
• Neurologist involvement allows for prompt diagnosis of alternative pathology and implementation of appropriate interventions 2