Disclosures: Seth Bires, DO: No financial relationships or conflicts of interest

Case Diagnosis: 50-year-old male with recurrent fevers and persistent encephalopathy after left frontoparietal intraparenchymal hemorrhage (IPH) thought to have central storming, later diagnosed with superimposed IPH infection.

Case Description: The patient suffered a left frontoparietal IPH causing right sided hemiparesis, aphasia, and encephalopathy. Acute hospital course was complicated by high intracranial pressures, requiring prolonged external ventricular drain placement. He had recurrent fevers despite treatment for Staphylococcus hominis bacteremia, with no other sources identified. The fevers were attributed to central storming and treated with propranolol with temporary improvement. At the inpatient rehabilitation facility (IRF) he continued to have intermittent fevers, mild leukocytosis, and persistent encephalopathy. Infectious workup was negative and MRI unable to be obtained given patient agitation. He was started on a course of empiric antibiotics with concern for central nervous system infection. He then suffered a new seizure and was transferred to acute care.

Setting: Inpatient RehabAssessment/

Results: At acute care, MRI showed left frontal lobe lesion enhancement adjacent to hematoma and along the previous ventricular device tract concerning for infection versus mass. He underwent a left parietal craniotomy with cultures initially negative, but PCR testing revealed Staphylococcus epidermidis. He was started on a six-week course of intravenous vancomycin for superimposed infection of the intraparenchymal hematoma. He was then transferred back to the IRF with marked improvement in cognition, cessation of recurrent fevers, and notable improvement in functional ability.

Discussion: Recurrent fevers are often attributed to disruption of central structures involved in temperature hemostasis following IPH, especially following a negative infectious work up and prolonged treatment with antibiotics. In the case presented, the source was identified on MRI, necessitating craniotomy with PCR testing to determine correct antibiotic regimen.

Conclusion: Super-infections of intracranial hematomas should be considered with intermittent fevers and persistent encephalopathy in patients with IPH, especially with prolonged use of external ventricular devices.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/the-imperfect-storm-infection-of-intraparenchymal-hemorrhage-misdiagnosed-as-central-storming-a-case-report/