A challenging case of prolonged fever with acute kidney injury and multifocal neurological involvement: A diagnostic and therapeutic dilemma

Leema Rebekal Rosy 1, Menaka 2, Esthar Rani 3

1Assistant Nursing Superintendent, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

2Nursing Incharge, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

3Nursing Superintendent, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

Abstract

We present the case of a 65-year-old male admitted with high-grade fever, chills, and syncope for 1.5 months. He had previously received multiple antibiotic courses at other centres without improvement. On admission, he was found to have severe azotemia, metabolic acidosis, and systemic inflammatory features. The patient later developed neurological symptoms, and MRI revealed multifocal lesions in the brain and spine suggestive of infective meningoencephalomyelitis. Multiple differential diagnoses, including infective, autoimmune, and vasculitis etiologies, were considered with a multidisciplinary approach involving nephrology, neurology, and infectious disease teams, he received tailored antibiotic therapy and supportive care, including hemodialysis. The patient showed gradual clinical improvement and was discharged after one month. This case highlights the complexity of prolonged fever with multiorgan involvement and the importance of stepwise evaluation, interdisciplinary collaboration, and clear communication with patient attendants. Prolonged fever, acute kidney injury, meningoencephalomyelitis, diagnostic challenge, critical care, multidisciplinary management

Introduction

Prolonged fever remains one of the most challenging presentations in internal and critical care medicine. It often involves extensive differential diagnoses encompassing infections, autoimmune diseases, and malignancies. The diagnostic process becomes particularly complex when systemic inflammation affects multiple organ systems such as the kidneys and central nervous system (CNS).

This report presents a case of prolonged fever with acute kidney injury (AKI) and multifocal neurological involvement, where delayed diagnosis and therapeutic challenges tested both clinical reasoning and communication within the treating team.

A 65-year-old male was admitted with complaints of high-grade fever and chills for 1.5 months and one episode of syncope. He was treated in two other hospitals before presentation, receiving multiple empirical antibiotic courses with no clinical improvement.

On Examination

General conditionDistressed and dehydrated
Facial puffinessPresent
Pedal edemaBilateral pitting type
TemperatureFebrile
PR82/min
RR30/min
SpO₂98% on room air
CVSS1S2 (+), tachycardia (+)
RSBilateral NVBS (+)
P/AMild distension, non-tender
CNSMoving all limbs, initially no focal deficits

Investigations

Initial laboratory investigations revealed:

  • Serum creatinine: >8 mg/dL
  • Severe metabolic acidosis
  • Electrolytes: Hyponatremia and hyperkalaemia
  • CBC: Neutrophilic leukocytosis
  • ESR/CRP: Markedly elevated
  • ANA: Negative
  • C3/C4: Low
  • Blood and urine cultures: Sterile

Echocardiography: Normal cardiac function; no vegetations or endocarditis.

MRI Spine: Multiple cystic lesions in the thoracic and lumbar vertebrae with paravertebral and epidural extension, suggestive of infective spondylodiscitis.

MRI Brain: Ring-enhancing lesion in the right frontoparietal region with surrounding edema consistent with cerebral abscess or meningoencephalitis.

Clinical Course

The patient was managed initially with IV ceftriaxone and vancomycin along with hemodialysis support. Given the sterile cultures, lack of endocarditis, and neurological involvement, a diagnosis of infective meningoencephalomyelitis with acute kidney injury was considered.

Lumbar puncture revealed mildly turbid CSF with raised protein and lymphocytic pleocytosis. Cultures and viral PCR panels were negative. Infective etiology was still suspected, and empirical coverage for Staphylococcus aureus and Gram-negative bacilli was continued.

During hospital stay, the patient’s renal function gradually improved with serial dialysis sessions. Later, the nephrology team initiated low-dose immunosuppressive therapy due to possible autoimmune overlap (low complements, non-resolving inflammatory state).

Neurological status stabilized, and repeat MRI showed regression of lesion size. Over 4 weeks, the patient’s fever subsided, renal parameters improved, and inflammatory markers normalized.

The patient required prolonged ICU and ward stay for over a month due to diagnostic complexity and treatment course. Initially, his attendant expressed dissatisfaction due to the diagnostic delay, but later was convinced after steady improvement and thorough counselling.

Nursing Diagnosis and Management

Hyperthermia related to infection

Goals: Maintain body temperature within normal range, prevent complications.

Nursing Interventions:

  • Monitored temperature every 4 hours and documented trends.
  • Provided tepid sponging and ensured adequate hydration.
  • Administered antipyretics as prescribed and observed response.
  • Maintained aseptic precautions during all invasive procedures.
  • Educated the patient and family about infection control and hygiene.

Evaluation: Temperature stabilized; no secondary infection developed.

Fluid and Electrolyte Imbalance related to renal dysfunction

Goals: Maintain optimal fluid balance and stable electrolyte levels.

Nursing Interventions:

  • Strict input–output monitoring; maintained daily fluid balance chart.
  • Monitored for signs of dehydration or fluid overload (pedal edema, weight changes).
  • Coordinate dialysis schedule; ensured aseptic care during vascular access.
  • Administered IV fluids and electrolyte corrections as per nephrology advice.
  • Educate patient and family about dietary sodium and potassium restriction.

Evaluation: Fluid balance maintained; renal parameters improved with dialysis.

Risk for Infection related to invasive devices and immunosuppression

Goals: Prevent hospital-acquired infections and cross-contamination.

Nursing Interventions:

  • Maintained sterile technique for all catheter and IV line care.
  • Followed central line and dialysis catheter care bundles.
  • Regular hand hygiene audits and environment disinfection done.
  • Early identification and reported signs of infection (fever spikes, pus discharge).
  • Educated attendant regarding personal hygiene and infection prevention.

Evaluation: No new infection acquired during hospital stay.

Risk for Impaired Cerebral Tissue Perfusion related to meningoencephalitis

Goals: Prevent neurological deterioration and monitor for early changes.

Nursing Interventions:

  • Performed hourly neurological assessment (GCS, pupillary response, limb movement).
  • Monitored for headache, vomiting, altered sensorium, or seizure activity.
  • Maintained head elevation at 30 degrees and prevent neck flexion.
  • Administered anticonvulsants and antibiotics as per prescription.
  • Collaborated with neurology team for ongoing evaluation.

Evaluation: No further neurological deficit; gradual improvement in alertness and orientation.

Anxiety and Knowledge Deficit in Family related to prolonged illness and diagnostic uncertainty

Goals: Reduce family anxiety and improve understanding of disease and care plan.

Nursing Interventions:

  • Provided daily updates and reassurance regarding patient progress.
  • Encouraged family participation in care decisions and basic patient support.
  • Explained all diagnostic and treatment procedures in simple terms.
  • Provided psychological support

Evaluation: Family demonstrated improved understanding and cooperation; anxiety levels reduced.

Patient and Family Education

  • Medication adherence: Importance of completing full antibiotic course and continuing prescribed nephrology medications.
  • Diet advised: Low-sodium, renal-friendly diet; adequate hydration; avoid nephrotoxic drugs.
  • Follow-up care: Regular nephrology and neurology reviews; timely blood tests to monitor kidney function.
  • Infection prevention: Hand hygiene, safe food and water practices.
  • Warning signs: Fever, altered behaviour, limb weakness, or decreased urine output to report immediately.

Continuous education and reassurance improved patient compliance and family confidence, contributing significantly to recovery.

Discussion

Diagnostic Challenges

This case underscores the difficulty of diagnosing prolonged fever with multiorgan dysfunction, particularly in an elderly patient with overlapping renal and neurological symptoms.

The differential diagnosis initially included:

  • Infective causes: Pyogenic bacterial infection, tubercular spondylodiscitis, brain abscess
  • Autoimmune causes: Vasculitis, lupus nephritis, ANCA-associated glomerulonephritis
  • Malignant causes: Lymphoma or metastatic lesions

The negative cultures and serologies created diagnostic uncertainty. Imaging played a pivotal role in guiding diagnosis. MRI findings showing ring-enhancing lesions in both spine and brain raised suspicion of disseminated bacterial infection or neurotuberculosis. However, the acute presentation and neutrophilic response favoured a pyogenic etiology.

Multisystem Involvement

The coexistence of acute kidney injury and CNS infection suggests a systemic inflammatory or septic process. In this patient, azotemia was multifactorial—likely due to sepsis-associated AKI, dehydration, and possible immune-mediated glomerulonephritis. The progression to metabolic acidosis and need for haemodialysis demonstrated the severity of renal insult.

Neurological manifestations emerged later, emphasizing how systemic infections can evolve to involve the CNS. The ring-enhancing lesion seen on MRI, along with clinical response to antibiotics, confirmed an infective meningoencephalitis component.

Importance of a Multidisciplinary Approach

The case was managed through collaboration among critical care, nephrology, neurology, neurosurgery, and infectious disease teams. Such coordination is vital when diagnostic ambiguity exists. Regular interdisciplinary discussions allowed timely decision-making—such as initiating haemodialysis, adjusting antibiotic regimens, and interpreting serial MRI findings.

Communication and Ethical Aspects

Diagnostic uncertainty often leads to anxiety among patients and families. Initially, the patient’s attendant expressed frustration, perceiving delays in diagnosis. Open communication, regular updates, and transparent discussions about diagnostic limitations helped rebuild trust. This aspect highlights the critical role of empathetic communication in ICU practice.

Lessons Learned

Persistently unexplained fever with multiorgan dysfunction warrants comprehensive re-evaluation rather than empiric antibiotic escalation.

Imaging correlation (especially MRI) is invaluable when systemic infections involve the CNS or spine.

Multidisciplinary management improves outcomes in complex systemic infections. Family counselling and transparency prevent conflict and preserve trust during prolonged hospitalizations.

Clinical Outcome

Following continued treatment, renal parameters normalized (serum creatinine <2 mg/dL) and neurological symptoms resolved. The patient was discharged in stable condition with advice for regular nephrology and neurology follow-up.

Conclusion

This case illustrates the complexity of managing prolonged fever with renal and neurological involvement. Despite negative cultures and overlapping clinical features, a systematic and multidisciplinary approach led to the identification of the underlying infective process and favourable recovery. The case emphasizes that persistence in diagnosis, coordinated care, and effective communication are cornerstones of successful outcomes in critical care.

Nightingale Journals

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