I thought I'd share this sad but interesting case to see if anyone has any input/experience. I have had a very sick 56 y/o male with covid. 10 days in. Intubated. Max vent 100% FIO2 doing poorly. Suddenly - two days ago - he spikes a temp of 108 deg F!! Concomitantly, he develops acute renal failure (Cr 0.8 to 3.9), shock, severe hypercarbia (CO2 50s to 95). Meds included propofol, precedex and fentanyl due to severe psychomotor agitation. Vancomycin for strep mitis bacteremia, and the usual covid meds. No volatile anesthetics/gas, no succinycholine, no antipsychotics or other offending agents seen with MH.

Anywany, inexorably, over next 24 hrs temps remain 107-108. Dantrolene is given with no effect. Cooling blankets. Propopfol and precedex are stopped. Head CT neg. Progressive shock and renal failure continue. He passed last night. No autopsy.

CK was 1000. +myoglobulinuria.

This pattern is classic MH. I don't think the bacterial infection caused this. Is covid related? If so - how? Has anyone seen a fever this high with cytokine storm?

Propofol syndrome? Maybe but I have not seen temps that high with it.

I thought about adrenal apoplexy, but we were'nt able to get an abd CT.

He may have had the autosomal dominant mutation described in MH pts of the ryanodine receptor (rare) but who knows.

A mystery. As is so often the case in medicine. And covid makes it harder to understand.

I agree with your instincts. Sure looks like MH, odd & sad case.

Write it up!

Otherwise I'm not going to be any help

Just saw a case similar to this a few days ago. My hospital's intensivist was run thin, so I offered assistance fielding some of their calls given our ER is right next to our ICU. I get a call that one of their patients appears to be about to code. I walk in to see her core temp is 110.5 F, her a-line has clotted off, and they are unable to get a blood pressure but has a palpable pulse, despite being on levo and vaso already. Unable to assess muscle rigidity as she is on a vec drip. Her sats have been between 60-80% the entire day despite being on 100% FiO2, maxed out on peep, proned, and receiving inhaled NO. They considered her for ECMO the day prior, but she was considered to be a poor candidate due to her obesity.

I had the nurses start the ArticSun cooling system and grab as many buckets of ice water as they could. We did cool water bladder lavage, gastric lavage, ice packs in axilla and groin, basically poured buckets of ice water on the patient to assist with evaporative cooling, but unfortunately the hospital refused to provide fans to assist in evaporative cooling efforts due to infection control issues, and the entire unit was a balmy 85F due to the AC being turned off to prevent the possibility of aerosolization of COVID into the vent system, so we basically had myself and 4 nurses fanning this patient by hand.

The best we could do was get her temp down to 107F despite all our efforts. My presumption regarding the pathophysiology, at least for my case was that this was probably due to anoxic brain injury leading to disruption of the thermoregulation center of the hypothalamus.

The patient ended up passing later that evening despite a heroic effort from those caring for her. She was only 36.

Dr. Not Yet Dr. Ag said:

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Just saw a case similar to this a few days ago. My hospital's intensivist was run thin, so I offered assistance fielding some of their calls given our ER is right next to our ICU. I get a call that one of their patients appears to be about to code. I walk in to see her core temp is 110.5 F, her a-line has clotted off, and they are unable to get a blood pressure but has a palpable pulse, despite being on levo and vaso already. Unable to assess muscle rigidity as she is on a vec drip. Her sats have been between 60-80% the entire day despite being on 100% FiO2, maxed out on peep, proned, and receiving inhaled NO. They considered her for ECMO the day prior, but she was considered to be a poor candidate due to her obesity.

I had the nurses start the ArticSun cooling system and grab as many buckets of ice water as they could. We did cool water bladder lavage, gastric lavage, ice packs in axilla and groin, basically poured buckets of ice water on the patient to assist with evaporative cooling, but unfortunately the hospital refused to provide fans to assist in evaporative cooling efforts due to infection control issues, and the entire unit was a balmy 85F due to the AC being turned off to prevent the possibility of aerosolization of COVID into the vent system, so we basically had myself and 4 nurses fanning this patient by hand.

The best we could do was get her temp down to 107F despite all our efforts. My presumption regarding the pathophysiology, at least for my case was that this was probably due to anoxic brain injury leading to disruption of the thermoregulation center of the hypothalamus.

The patient ended up passing later that evening despite a heroic effort from those caring for her. She was only 36.

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So thankful there are people like you and that team out there fighting for every inch under unimaginable conditions.