Pure distraction injury of T1-2 with quad fever

We report a pure distraction injury of the upper thoracic spine and uncontrolled hyperthermia without an infectious cause. Quad fever appears in the first several weeks to months after a cervical or upper thoracic SCI and is characterized by an extreme elevation in body core temperature beyond 40 °C without an infectious cause. Discriminating between infectious and noninfectious causes is important, and a thorough clinical assessment is required.

A 52-year-old male visited the emergency room complaining of back pain with complete paralysis [American Spinal Injury Association (ASIA) A] of both lower extremities after a pedestrian-motor vehicle accident. He had trouble breathing due to a hemothorax and flail chest caused by fractures of the right second to eleventh and left fourth to seventh ribs. A computed tomography scan revealed severe distraction of the T1-2 intervertebral space. A magnetic resonance image showed signal changes in the spinal cord and a clean-cut margin between the T1-2 disc and T2 body. The neurological level of injury was C8 upon the initial neurological assessment. Emergency surgery was performed. C6-T3 posterior instrumentation and an autologous iliac bone graft were performed.

After surgery, the core temperature increased gradually to above 38.0 °C on post-trauma day 4 and increased to 40.8 °C on post-trauma day 7. None of the repeated aerobic, anaerobic, or fungal cultures of the blood, tracheal aspirate, line tips, urine, or stool was positive until post-trauma day 21, when Candida tropicalis was identified in the urine culture. On post-trauma day 63, the blood pressure, pulse, and body temperature stabilized and the patient was transferred to the general ward. At post-trauma year 6, the injury state was still complete and the neurological level of injury was changed to C4.

Based on the Grand Round case and relevant literature, we discuss the case of pure distraction injury of T1-2 with quad fever. Spinal surgeons should be knowledgeable regarding quad fever as well as the differential diagnoses and treatment strategies.