Can Central Fever Present in Awake Patients with TBI?
Yes, central fever can present in awake patients with traumatic brain injury, though it is more commonly recognized and studied in severely injured, sedated patients. The literature predominantly focuses on severe TBI cases requiring sedation and ventilation, but central fever is documented across the spectrum of TBI severity, including in patients during the rehabilitation phase who are clearly awake and interactive.
Evidence Across the Consciousness Spectrum
Severe TBI (Typically Sedated)
- The majority of guideline recommendations focus on severe TBI patients who are sedated and ventilated, where controlled normothermia (36.0-37.5°C) should be initiated reactively when fever is detected 1
- These patients typically have Glasgow Coma Scale scores of 3-4 with decorticate posturing and autonomic dysfunction manifested by tachycardia and profuse sweating 2
Awake and Rehabilitating Patients
- Central fever has been documented in awake TBI patients during the acute rehabilitation setting, with an incidence of approximately 4% in one consecutive series of 84 TBI patients participating in rehabilitation programs 3
- Patients in rehabilitation are by definition awake enough to participate in therapy, yet still developed neurogenic fever requiring systematic evaluation 3
- One case report describes a patient who developed intermittent temperature elevations during thermal stress in the post-acute phase while clearly interactive enough to participate in laboratory testing sessions 4
Clinical Characteristics in Awake Patients
- Central fever presents as persistent temperature elevations (>37.5°C) without a cyclic pattern, regardless of consciousness level 5
- The diagnosis remains one of exclusion after ruling out infectious and inflammatory causes through thorough workup including chest radiograph, blood cultures (at least two sets, 60 mL total), and consideration of CT imaging 6
Important Clinical Pitfall
The primary danger is assuming central fever only occurs in comatose patients and therefore failing to consider it in awake TBI patients with unexplained fever. This can lead to:
- Prolonged unnecessary antibiotic use while searching for non-existent infections 1
- Uncontrolled fever causing secondary brain injury through increased metabolic demands, enhanced excitatory neurotransmitter release, and elevated intracranial pressure 6
- Missed opportunity for appropriate treatment, as fever is associated with worse outcomes particularly in elderly patients (>65 years) with TBI 7
Management Approach for Awake Patients
- The same diagnostic algorithm applies: perform thorough infectious workup before diagnosing central fever 6, 3
- For awake patients desiring symptomatic relief, antipyretic medications are recommended over non-pharmacologic cooling methods 6
- In cases where central fever is confirmed, propranolol (20-30 mg every 6 hours) has been shown to reduce temperatures by at least 1.5°C within 48 hours and should be continued until signs of autonomic dysfunction abate 2
- Monitor for chronic thermoregulatory deficits, as some patients develop intermittent temperature elevations during thermal stress even in the post-acute phase 4