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Discussion

neuro/autonomic dysfunction fevers?

I am trying to find some other causes of frequent fevers/temperature instability. I've been taking care of a 13 mo old w/hx of AV canal repair months ago. Now with severe pulm htn, trach/vent dependent. She's been relatively stable the past few weeks and discharge planning is in the process. The biggest issue lately are the fevers she spikes. She's been pan cultured more days than not and hasn't got a thing growing anywhere, plus she doesnt look/act sick at all. She has lived the past few weeks on a cooling blanket that's turned on as soon as she hits 37.8 rectally. She is happiest around 36.4 and miserable when hot with an elevated HR, decreased sats, irritability and inability to sleep, when cooler she's happy & pleasant. Most nurses now suspect something neuro to be the issue or an autonomic dysfunction, however being a cardiac icu the docs haven't been to interested in further pursuing these possibilities. I know there are kids that live at home with cooling vests for a variety of reasons and I'm just wondering what your thoughts/experiences are.

Some docs have mentioned "lasix or steroid fevers" which I've never heard of but please enlighten me if you have...she is chronically lasix dependent and has been on/off/on steriods to try to help her lungs.

Also when she spikes, she spikes FAST. The other day the blanket was off and she was 36.3 when I went to lunch, when I came back she was 38.1, happened w/in an hour. Poor thing is never wearing clothes either...but she can't be naked the rest of her life!

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    I have a noonan's baby, female 8 mo with exactly the same issue. We were getting ready to send her home after finally adjusting to LTV vent and getting her high capacity concentrator since she's on 5 L base line... and then she got temp of 104 with no bacteria in blood or sputum. One day after she was back to 96 range where she's the most comfortable but still had to stay over for the weekend. Parents were heart broken as were we, but the bottom line is no one had an answer why did she spiked so high and then came back just as fast. Our girl is also 99% of the time in her diaper only since any cover or clothing gets her to 99 range and her just vegals on us with HR of 60 and under. I know this doesn't help you but if someone can put those two together I would be glad to know.

    Thanks

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    ... just vegals on us with HR of 60 and under

    I had to ponder that for a moment, the realized you were talking about "vagal" brady. I haven't noted autonomic instability to be linked with high vagal tone, but I guess there could be a connection. umcRN, does your patient have T21 along with the rest? There's a high incidence of hypothyroidism in those kids, but that typically results in subnormal temps. Sometimes these rapid, bizarre fluctuations in temps result from the onset of hemophagocytic lymphohistiocytosis, but that's quire rare... A more likely cause could be extravascular, extrapulmonary fungal infection - the kind that is notoriously hard to diagnose and even harder to treat. These infections are not uncommon in children who have been hospitalized long-term. Maybe you could suggest these kids be worked up with it in mind.

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    She does have Tri21 and hypothyroidism jan! haha always a wealth of knowledge you are! She has had fungal cultures sent. Would what you mention be something different? A different test? I've seen kids with fungal infections before too and they are usually (from what I have seen) very sick, which she doesn't appear to be at all. She is quite pleasant and happy 99% of the time. And no other lab work shows sepsis. Although you say extravascular so does it not show up in blood work? Infectious disease team has been following her as well

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    I know we've isolated fungi from children with FUO who didn't seem to be sick, just spiking temps, mildly elevated WBC and with an elevated C-reactive protein. We usually find it in pleural fluid, peritoneal fluid, swabs from mediastinal or peritoneal washouts or on CT. Fungal balls in the liver, for example, are not going to seed the blood, but can cause these odd fevers and have a characteristic appearance on CT. Once they've been treated for a couple of weeks with fluconazole, or maybe voriconazole for specific strains, they stop with the fevers and eventually recover. You're right, fungemia is one of those things that makes kids REALLY sick... but a lot of times the loculated or occult fungal infections don't. Anyway, it's just a thought.

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    Thanks Jan! Now that you mention it I took care of a poor baby a while ago who had fungal balls in his eyes! :eek: it was awful, ophthalmology had to come given him eye injections every day :-(

    Anyways, i'm headed onto a few weeks of night shift and you know unless you're dying nothing happens at night ;) but I will try to suggest it to the docs/oncoming nurses if I happen to take care of her on any of my shifts.

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    The only other thing I can think of is the C-reactive protein level and perhaps a cortisol level.

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