A Teenager With Fever Who Can’t Talk After Visiting Mexico

Colleen Mathis, MD; Kimberly Monroe, MD, MS

Disclosures

October 30, 2020

Physical Examination and Workup

Upon physical examination, the patient's temperature is 98.2°F (36.8°C), blood pressure is 133/81 mm Hg, heart rate is 145 beats/min, respiratory rate is 36 breaths/min, oxygen saturation is 100% in room air, and weight is 71.65 lb (32nd percentile). She appears nontoxic. Her head and neck examination is unremarkable, other than tenderness of the bilateral temporal areas. She is tachycardic, with normal S1 and S2 sounds and no murmurs. She is tachypneic, with clear lungs throughout and no accessory muscle use. Mild generalized abdominal and chest tenderness are present, with a soft abdomen and no guarding or rebound.

Preliminary laboratory findings are notable for a white blood cell count of 16,200/µL, hemoglobin level of 10.9 g/dL, platelet count of 309,000/µL, erythrocyte sedimentation rate of 23 mm/h, and C-reactive protein level of 3.7 mg/dL. Her electrolyte and liver enzyme findings are unremarkable. Blood culture results are pending, and urinalysis is negative. She is admitted for further evaluation of her fever of unknown origin.

The next morning, the patient develops a fever (100.8°F [38.2°C]), with persistent resting tachycardia (142 beats/min) and tachypnea, even while afebrile. She has abdominal pain, loose stool, and an episode of vomiting. She continues to have headache, which awakens her from sleep. Upon examination, she has new-onset disorientation, with word-finding difficulty.

A brain MRI is obtained; it was substantially limited by artifact from the patient's braces but otherwise revealed no acute intracranial abnormality (Figure 1).

Figure 1.

Lumbar puncture is performed, and initial cerebrospinal fluid studies are negative, including cell count, differential, and Gram stain. Pediatric rheumatology and infectious disease specialists are consulted.

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