Diagnostic dilemma of a young man with Fever and headaches.

A 23-year-old man was admitted to the hospital in the fall because of fever and headache. He had been well until 5 days earlier when he developed headaches associated with photophobia, neck pain, nausea, and vomiting. He had no significant medical history and took no medications. He lived with his parents in Seattle, Washington, and took classes at a local college. He had immigrated from China in 2007. The patient was alert and interactive. The temperature was 40.0°C, blood pressure was 161/92 mm Hg, pulse was 91 beats/min, and oxygen saturation was 100% on room air. His general examination revealed anicteric sclerae and no skin rash. Pain was noted with passive neck flexion. On neurologic examination, the patient was oriented with fluent speech and no dysarthria. Visual fields and extraocular movements were full. The remaining cranial nerve functions were intact. Muscle bulk and strength were normal. Sensation was preserved with no extinction detected. The tendon reflexes were equal at 2+, and plantar responses were flexor. There was no dysmetria on finger-to-nose testing. The gait was normal. Laboratory studies including a basic metabolic panel, liver function tests, coagulation studies, and urinalysis were notable only for a low sodium of 135 mEq/L (ref 136-145 mEq/L) and an elevated white blood cell count of 13 000/μL (ref 4.30-10.00 thousand/μL). Blood cultures were obtained. Chest radiograph revealed clear lungs and pleural spaces. Computed tomography (CT) of the head showed no abnormalities. The results of cerebrospinal fluid (CSF) analysis are shown in Table 1. Table 1. Cerebrospinal Fluid Analysis Dexamethasone, vancomycin, ceftriaxone, and acyclovir were started for possible bacterial or viral meningitis but discontinued once the blood cultures, CSF Gram stain and bacterial cultures, and viral polymerase chain reaction (PCR) tests were negative. Contrast-enhanced magnetic resonance imaging (MRI) of the brain was normal. The patient was discharged home after 3 days with a diagnosis of viral meningitis. Five days after initial discharge, the patient returned to the hospital with lethargy and confusion. His mother reported that he was less responsive, intermittently mumbling in response to questions, and requiring assistance with basic daily functions. The patient was drowsy and disoriented. The temperature was 38.2°C, blood pressure 119/90 mm Hg, and pulse 116 beats/minute. On examination, he exhibited neck stiffness, incoherent speech, and impaired comprehension. Serum sodium was 121 mEq/L and white blood cell count was 15 500/μL. Head CT showed mild dilatation of the third and lateral ventricles compared to the study 5 days before. Contrast-enhanced brain MRI demonstrated abnormal enhancement of the prepontine and interpeduncular cisterns (see Figure 1). Human immunodeficiency virus (HIV) test was negative. Repeat CSF analysis is shown in Table 1. Figure 1. Magnetic resonance scans of the brain. A, T1 fat-saturation postcontrast axial magnetic resonance image on initial presentation shows normal contrast enhancement. B, T1 postcontrast axial image 5 days later shows mild enhancement of the interpeduncular ... Antibiotics and antiviral medications were restarted. On hospital day 2, the patient had a witnessed convulsive seizure. Repeat head CT showed worsening hydrocephalus. An external ventricular drain was placed, and the patient was given a loading dose of phenytoin. The patient’s mother reported that the patient may have been exposed to an uncle with active pulmonary tuberculosis, leading to the initiation of antituberculous medications, including rifampin, isoniazid, pyrazinamide, and ethambutol. Three days after readmission, a presumptive mold grew in the CSF bacterial cultures. A rash was also noted on the patient’s right flank, consisting of plaques and papules with a central pearly pink color. A skin punch biopsy and additional laboratory studies were obtained, including antinuclear antibody (negative), rheumatoid factor (<13 IU/mL; negative), aspergillus galactomannan assay (0.114; negative), and Quantiferon-TB Gold (indeterminate). Upon further questioning, the patient’s mother reported the patient had spent 8 months in California 1½ years before. Liposomal amphotericin B was started. Six days after readmission, the results of 2 diagnostic tests were received.