What is the differential diagnosis for a patient presenting with high fever, vertigo, and coughing?

Differential Diagnosis: High Fever, Vertigo, and Coughing

The combination of high fever with vertigo and cough most urgently suggests infectious labyrinthitis or vestibular neuritis, but you must immediately rule out life-threatening central causes (stroke, meningitis) and severe respiratory infections with secondary vestibular involvement before settling on a benign peripheral vestibular diagnosis. 1, 2, 3

Immediate Life-Threatening Considerations

Central Nervous System Pathology

• Posterior circulation stroke must be excluded first—look for dysarthria, dysphagia, visual blurring, drop attacks, or limb weakness/numbness, which distinguish stroke from peripheral vestibular causes 1, 3
• Vertigo lasting minutes with severe imbalance, nausea, and vomiting without hearing loss suggests ischemia; these insults are permanent and non-fluctuating 1
• Red flags requiring emergency imaging: direction-changing nystagmus without head position changes, downbeating nystagmus, severe imbalance disproportionate to vertigo, or any focal neurological deficits 3

Infectious Causes with Fever

• Bacterial or viral labyrinthitis presents with sudden severe vertigo, profound hearing loss, and prolonged vertigo (>24 hours) accompanied by fever and severe otalgia 1, 2
• The vertigo is accompanied by nausea and hearing loss but is not episodic or fluctuating like Ménière's disease 2
• Losses in infectious labyrinthitis are often permanent and do not fluctuate, distinguishing it from Ménière's disease 1

Primary Differential Based on Symptom Constellation

Infectious Labyrinthitis (Most Likely Given Fever + Vertigo + Cough)

• Viral or bacterial infection (adenovirus, staph/strep) can lead to complete hearing loss and vestibular crisis with prolonged vertigo 1
• COVID-19-induced labyrinthitis has been documented, presenting with vertigo, hearing loss, tinnitus, and aural fullness, often with mild respiratory symptoms 4
• The cough may represent the primary viral infection that subsequently involves the inner ear 4, 5

Vestibular Neuritis with Concurrent Respiratory Infection

• Vestibular neuritis causes acute prolonged vertigo (12-36 hours) with severe rotational vertigo, nausea, and vomiting without hearing loss, tinnitus, or aural fullness 1, 2
• COVID-19-induced vestibular neuritis has been reported in patients presenting with intractable vertigo without typical respiratory symptoms 6, 5
• In one study, 85.7% of post-COVID-19 patients with vertigo had vestibular neuritis 5

Severe Respiratory Infection with Secondary Vestibular Symptoms

• High fever with cough suggests pneumonia, bronchitis, or COVID-19 as the primary process 6, 4
• Vertigo may be a presenting symptom or sequela of COVID-19 infection, mainly attributed to peripheral vestibular dysfunction 5
• The pathophysiology of viral-induced vestibular neuritis follows similar mechanisms regardless of the specific virus 6

Less Likely but Important Differentials

Autoimmune/Inflammatory Conditions

• Multiple sclerosis can present with progressive fluctuating bilateral hearing loss that is steroid-responsive, along with vision, skin, and joint problems 1
• Systemic inflammatory conditions may present with fever, respiratory symptoms, and vestibular involvement 7

Vestibular Migraine

• Presents with attacks lasting hours (can be minutes or >24 hours) with more photophobia than visual aura 1
• Hearing loss is less likely than in Ménière's disease, and fever would be atypical 1

Ménière's Disease (Unlikely with Fever)

• Requires two or more spontaneous vertigo attacks lasting 20 minutes to 12 hours with fluctuating aural symptoms 1
• Fever is not a typical feature, making this diagnosis less likely in your patient 1

Benign Paroxysmal Positional Vertigo (BPPV)

• Causes positional vertigo lasting seconds, not associated with hearing loss, tinnitus, or aural fullness 1
• Fever and cough would not be explained by BPPV alone 1

Critical Diagnostic Algorithm

Step 1: Rule Out Central Causes

• Perform targeted neurological examination for dysarthria, dysphagia, visual disturbances, motor/sensory deficits, or Horner's syndrome 3
• Check for direction-changing nystagmus, downbeating nystagmus, or baseline nystagmus without provocative maneuvers 3
• Emergency neuroimaging if any red flags present 3

Step 2: Assess Vestibular Pattern

• Duration of vertigo: Seconds (BPPV), minutes (stroke/TIA), hours (Ménière's/migraine), or >24 hours (labyrinthitis/neuritis) 1, 2
• Hearing involvement: Present in labyrinthitis, absent in vestibular neuritis 1, 2
• Fluctuation: Episodic and fluctuating suggests Ménière's; single prolonged attack suggests labyrinthitis 1, 2

Step 3: Evaluate Infectious Etiology

• Check for severe otalgia, which suggests bacterial infection requiring urgent treatment 1
• Consider COVID-19 testing given documented cases of vestibular involvement 6, 4, 5
• Assess inflammatory markers, though they may be surprisingly normal even in viral vestibular neuritis 6

Step 4: Determine Treatment Urgency

• Immediate intervention: Any central red flags, severe otalgia with fever, or progressive neurological symptoms 1, 3
• Urgent evaluation: Symptoms lasting >24 hours without improvement, profound hearing loss, or severe imbalance 2, 3
• Outpatient management: Typical viral labyrinthitis or vestibular neuritis without red flags can be managed with symptomatic treatment and oral steroids 6, 4

Common Pitfalls to Avoid

• Do not dismiss neurological symptoms as anxiety when vertigo is accompanied by fever and respiratory symptoms 3
• Do not assume all vertigo with cough is benign—cough syncope exists but presents with loss of consciousness, not isolated vertigo 8
• Do not overlook subtle neurological signs in the presence of obvious vestibular symptoms; always check for dysarthria, dysphagia, and visual changes 3
• Do not delay imaging if vertigo persists >24 hours without improvement or if any central features are present 2, 3