P054: MALIGNANT HYPERTHERMIA OR NOT? RECONSIDERING THE DIFFERENTIAL DIAGNOSIS OF POSTOPERATIVE FEVER IN AN OTHERWISE HEALTHY PATIENT
Everett J Kim; Alana D Starr; Mogen Frenkel, Dr
Department of Surgery, Division of Anesthesiology, Florida Atlantic University Charles E. Schmidt College of Medicine, USA
Introduction/Background: Malignant hyperthermia (MH) is a rare but life-threatening autosomal dominant anesthetic complication characterized by skeletal muscle hypermetabolism following exposure to triggering agents. In the immediate postoperative period, MH may present with hyperthermia and hemodynamic instability, findings that overlap with other causes of acute deterioration including sepsis. This diagnosis overlap may complicate early assessment, especially when symptoms develop shortly after anesthesia initiation. Accurate differential is critical, as an MH diagnosis carries important implications for acute management and future anesthetic care.
Case Presentation: A 26-year old woman with her only significant medical history including childhood asthma, underwent outpatient surgical drainage of a Bartholin cyst abscess. In the immediate postoperative period, she developed acute fever and rapidly progressive hemodynamic instability. Given the temporal association with anesthesia, MH was suspected, prompting immediate transfer to a regional hospital and initiation of treatment for MH.
Subsequent evaluation demonstrated severe sepsis progressing to septic shock, requiring intensive care unit admission, vasopressor support, and broad-spectrum intravenous antibiotics. Initial computed tomography imaging was unrevealing, although repeat imaging identified a residual perineal abscess. This abscess was drained by Interventional Radiology and blood cultures grew Escherichia coli. Following source control and antimicrobial therapy, this patient’s hemodynamics improved. Despite stabilization, the patient experienced persistent rectal pain. Magnetic resonance imaging of the pelvis demonstrated a large perineal abscess with complex perirectal disease. The patient then underwent examination under anesthesia, which revealed a fistulous tract. The abscess was drained and an anterior seton placement which resulted in clinical improvement.
Several weeks later, the patient underwent colonoscopy to evaluate for inflammatory bowel disease due to the fistula formation. Given the prior concern for MH, a detailed anesthetic assessment was performed and a propofol-based anesthesia was selected. The procedure and anesthetic course were uneventful with no evidence of hypermetabolic response. Colonoscopy findings were normal, effectively ruling out inflammatory bowel disease.
Conclusion: This case highlights the diagnostic challenge of distinguishing MH from postoperative sepsis, as both may present with acute hyperthermia and hemodynamic instability in the perioperative setting. While empiric treatment for MH is appropriate when suspected, clinicians should remain vigilant for infectious etiologies as delaying appropriate antimicrobial therapy can have consequences. This case additionally demonstrates the potential long-term consequences of a persistent MH label, which may influence future anesthetic planning. Careful reassessment and precise documentation are therefore critical to guide appropriate management and prevent unnecessary long-term consequences.