13-Year-Old Boy Unaware of His Surroundings

Paul P. Rega, MD


September 14, 2023

Physical Examination and Workup

The patient's temperature is 102.6 °F (39.2 °C); heart rate is 113 beats/minute; respiration rate is 12 breaths/minute with shallow breaths; blood pressure is 102/54 mm Hg; and oxygen saturation is 93% (fraction of inspired oxygen, 2 L/minute by nasal cannula). His score on the Glasgow Coma Scale is 9-10. Nuchal rigidity is present. No rashes are observed, and no evidence of trauma is noted. Airway, breathing, and circulation stabilization is achieved with advanced resuscitative techniques. Broad-spectrum antimicrobial medications are administered.

Results of a CT scan of the brain and other radiologic imaging studies are interpreted as normal. The results of the initial laboratory studies are remarkable for a white blood cell (WBC) count of 16,000/µL (reference range, 4500-11,000/µL), with a left shift, and elevated levels of inflammatory biomarkers.

A lumbar puncture reveals these findings:

  • Opening pressure: 36 cm H2O (reference range, 10-20 cm H2O)

  • WBC count: 3690/µL (75% neutrophils) (reference range, 0-5/µL [< 2 polymorphonucleocytes])

  • Red blood cell (RBC) count: 423/µL (reference range, 0-10/µL)

  • Protein level: 425 mg/dL (reference range, 20-40 mg/dL)

  • Glucose level: < 10 mg/dL (reference range, 45-80 mg/dL)

The results of Gram staining are negative. Blood, urine, and cerebrospinal fluid (CSF) cultures are ordered. A more thorough analysis of the history prompts a request for a wet preparation of the CSF. The results point toward the presumptive diagnosis.


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