Step 1: View clinicals

A previously healthy 45-year-old man presents with a fever of 39˚C (102.2 ˚F) for two days. He also experienced nausea, photophobia, and a continuous generalized headache for one day. There is no history of weakness, vomiting, loss of consciousness, or seizures. He returned from Vietnam three days prior to the onset of symptoms. He had spent two weeks there as a tourist. He was bitten by insects multiple times, ingested seafood, and drank unboiled fresh water. There is no history of allergies. He only drinks socially, and does not smoke or use ilicit drugs. A complete blood count, liver and renal profiles, urinalysis, ECG, and chest x-ray are all unremarkable.

Step 2: Order all relevant investigations

Blood cultures

Culture results will be available in 48 to 72 hours.

Lumbar puncture

Opening pressure: 25 cmH2O (10-20) Appearance: mildly cloudy WBC: 500 cells/uL (0-5) Eosinophils: 44% Lymphocytes: 35% Monocytes: 11% Plasma cells: 10% Protein: 97 mg/dL (<45) Glucose 60 mg/dL (>50% plasma glucose) Gram stain: negative Ziehl-Neelsen stain: negative A random plasma glucose collected at the same time is 110 mg/dL (<180).

CSF serology for cryptococcus & angiostrongylus

Cryptococcal antigen: negative Polymerase chain reaction (PCR) for angiostrongylus: sample sent for processing to the Centers for Disease Control (CDC)

MRI brain

Magnetic resonance imaging of the brain shows no abnormalities.

Step 3: Select appropriate management


Score: ★★☆