Case 3: A man with headache

Chief complaint: Headache

History of present illness:
This is a 19 year old man who was in good health until he noticed 9 days ago that he had muscle aches. Four days ago he developed a fever but he doesn't recall how high. He developed a severe headache, as well as a little neck aching and stiffness, so he went to the emergency room. He was given a diagnosis of "flu", and was treated with ketorolac (Toradol ®). This made the headache better for a while, but it returned. The headache is severe, and he rates it as "10 on a scale of 1 to 10". The headache is bilateral periorbital, pounding, with photophobia, phonophobia, and nausea.

Allergies: None
Medications: Hydrocodone for pain.
Past medical history: Asthma
Family history: Mother suffers from migraines. Other family members have had hypertension and TIA.
Social: Smokes 1 pack of cigarettes per day. Does not use alcohol. Uses marijuana.

Physical examination:
Vital signs: Temperature 100 degrees F, Pulse 80 , Respiratory rate 16 , Blood pressure 120/82 , Weight 65 kg.
General physical exam: Normal except for moderate neck stiffness. Kernig's and Brudzinski's signs absent.
Neurological exam: Alert and cooperative. Mental status normal. Fundus examination normal. Cranial nerve, motor, sensory, reflex, coordination and gait exams normal.

Initial laboratory studies:
CBC and basic metabolic panel were normal.

Course of illness:
Meningitis was suspected, and a lumbar puncture was done. Fluid was clear. White blood cell count was 459 cells/cu. mm, with 97% lymphocytes. Red blood cell count was 1. Glucose was 62, protein 44. Gram's stain was negative. Bacterial and viral cultures were done.

1. What is the diagnosis?
2. Can you determine the most likely etiology?
3. What should be done for the patient?

[ back to CNS Infections ]