Continuous Intravenous Low-dose Diclofenac Sodium to Control a Central Fever After Ischemic Stroke in the Intensive Care Unit

A Case Report and Review of the Literature

L. G. Giaccari; M. C. Pace; M. B. Passavanti; P. Sansone; V. Esposito; C. Aurilio; V. Pota

Disclosures

J Med Case Reports. 2019;13(373) 

In This Article

Abstract and Introduction

Abstract

Introduction: Elevation in body temperature within the first 24 hours of ischemic stroke is fairly common and known to be associated with worse outcomes. Only after thoroughly ruling out infection and the noninfectious etiologies and in the appropriate clinical setting should the diagnosis of central fever be made. Acetaminophen and nonsteroidal anti-inflammatory drugs are typical therapeutic options. External cooling is frequently used when pharmacologic interventions are inadequate. However, reports have suggested that neurogenic fevers are somewhat resistant to traditional pharmacologic therapies.

Case presentation: We describe a case of a Caucasian patient with central fever after ischemic stroke not responsive to acetaminophen administration and external cooling. After an initial bolus of diclofenac sodium (0.2 mg/kg in 100 ml of saline solution for 30 minutes), a continuous infusion (75 mg in 50 ml of saline solution) was started. After 5 days of treatment, the patient's body temperature was below 37.5 °C, and the diclofenac sodium infusion was stopped.

Conclusions: We observed that a low-dose diclofenac sodium infusion was effective in treating fever without systemic side effects. This treatment may be suggested as an alternative to conventional antipyretic drugs, but additional clinical trials are required.

Introduction

Fever, defined as a core body temperature exceeding 37.5 °C, is common in patients with brain injury. It most often occurs within the first 2 days after a stroke, and its cause is not always easy to identify. In most cases, infection is the cause of fever after stroke. In severe stroke, massive tissue necrosis and the presence of blood in the brain can elevate body temperature.[1]

Fever resulting from a stroke-related pathologic process starts within 24 hours of stroke symptoms, whereas fever of other etiologies emerges at later time points. If infections, venous thromboembolism, drugs reported to cause hyperthermia, and postsurgical origins are excluded, early fever in patients with stroke can indicate a neurological origin.[1–3]

Elevation of temperature following stroke is likely the result of metabolic dissociation and heat production related to inflammatory cytokine release in response to the injury.[3]

The relationship between fever, neurologic outcome, and stroke size is greatest when the increase in temperature begins within the first 24 hours of neuronal injury.[3] Fever is associated with increased morbidity and mortality in patients with stroke, independent of the temperature elevation origin.[1–3]

International guidelines for patients with ischemic stroke recommend treating body temperature higher than 37.5 °C, searching for possible infection, and starting tailored antibiotic treatment. Multimodal cooling and antipyretics, such as acetaminophen, are recommended. The target temperature for patients with neurogenic fever is 37.0 ± 0.5 °C.[1]

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