From profound hypothermia to malignant hyperpyrexia: a case report of biphasic thermoregulatory crisis following acute high cervical spinal cord injury

BACKGROUND: Thermoregulatory dysfunction is a well-recognized yet underreported consequence of high cervical spinal cord injury (SCI). Patients may present with extreme temperature disturbances, ranging from profound hypothermia to malignant hyperthermia, reflecting severe autonomic dysregulation. Early recognition is crucial, as these abnormalities can rapidly become life-threatening. CASE PRESENTATION: A 55-year-old previously healthy man was found unconscious outdoors in the rain. Initial assessment revealed profound hypothermia (31 °C), bradycardia (48 bpm), hypotension (70/50 mmHg), and absent shivering. He was resuscitated with warmed intravenous fluids, external rewarming, hydration and vasopressor support. Neurological evaluation after stabilization demonstrated complete quadriparesis with sensory loss below C5 and bowel and bladder involvement (ASIA Grade A). Imaging revealed C5-C6 retrolisthesis with spinal cord compression. During hospital monitoring, he developed rapid-onset hyperpyrexia (42.2 °C) without sweating, refractory to conventional cooling, ultimately resulting in cardio-respiratory arrest. Extensive evaluation excluded infectious, metabolic, and drug-related causes, suggesting neurogenic/ quad fever secondary to high cervical SCI. CONCLUSIONS: This case illustrates the biphasic and rapidly progressive nature of autonomic thermoregulatory dysfunction in acute high cervical SCI. Neurogenic fever, though uncommon, may occur within hours and is associated with high morbidity and mortality. Continuous temperature monitoring, early hemodynamic stabilization, and high clinical suspicion are critical, particularly in resource-limited settings.