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This case examines the diagnostic challenges presented by extreme hyperpyrexia without identifiable infectious sources.

May 20, 2026

A54-08 109.9 °F: A Diagnostic and Critical Care Challenge

Key Points

This case examines the diagnostic challenges presented by extreme hyperpyrexia without identifiable infectious sources.
Emergent intubation and admission to ICU for severe shock and hyperpyrexia.
Utilization of targeted temperature management with the Arctic Sun device and broad-spectrum antimicrobials for possible CNS infection.
Conducted lumbar puncture and MRI, both negative for infection, along with EEG to assess neurological status.
Initial negative cultures and normal laboratory results indicated an absence of infection, but the patient exhibited signs of disseminated intravascular coagulation (DIC).
Despite temperature normalization and shock resolution, the patient experienced no meaningful neurologic recovery following treatment.
Considered non-exertional heat stroke as the primary cause, likely influenced by medications and ambient temperature.

Abstract

Abstract This case highlights a life-threatening presentation of extreme hyperpyrexia in an adult male without an identifiable infectious or toxicologic source, posing a significant diagnostic and management challenge in the ICU. Hyperpyrexia above 106 °F is a medical emergency, often linked with central nervous system dysfunction and multiorgan failure, and may result from sepsis, heat stroke, drug toxicity, neuroleptic malignant syndrome (NMS), or serotonin syndrome. A 56-year-old male from an assisted living facility presented with unresponsiveness, altered mental status, and a temperature of 109.9 °F. He was emergently intubated and admitted in severe shock. Targeted temperature management using the Arctic Sun device was initiated. There were no initial signs of infection- non-contrast CT chest, urinalysis, and cultures were negative. Leukocytosis was absent, initial creatine kinase was normal, and no rigidity was noted on exam.Due to hemodynamic instability, lumbar puncture was deferred. Broad-spectrum antimicrobials (vancomycin, cefepime, metronidazole, ampicillin, and acyclovir) were started empirically for possible CNS infection. The patient required multiple vasopressors for refractory hypotension. Labs showed evidence of Disseminated Intravascular Coagulation (DIC) and multiorgan dysfunction. After 48 hours of negative cultures and defervescence, antimicrobials were discontinued.A delayed lumbar puncture and MRI were negative for infection or structural brain injury. EEG revealed severe encephalopathy. Despite temperature normalization and shock resolution, there was no meaningful neurologic recovery.The patient was on valproic acid, olanzapine, and clonazepam. The outside temperature was near 90 °F, and individual patient rooms lacked air conditioning. While NMS and Serotonin Syndrome were considered, profound DIC pointed toward Non-Exertional Heat Stroke, a hallmark of direct thermal injury. This case highlights the complexity of evaluating hyperpyrexia with altered mental status. Contributing factors likely included olanzapine use, high ambient temperature, and lack of preventative measures. Prompt airway protection, temperature control, and hemodynamic support were critical, as hyperthermia can cause irreversible neurologic injury regardless of underlying etiology. This abstract is funded by: None

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