A 15-year-old previously healthy girl presented to the Emergency Department with fever, vomiting and headache. She was at a resort vacation in Cancun, Mexico, with her parents and brother when 5 days before admission she developed a sore throat associated with rigors and chills. The pharyngitis resolved but was followed by extreme lethargy, headache and a low grade temperature while on the plane ride home. During the next 2 days the headache worsened. It was described as bilateral, frontal and throbbing and was associated with photophobia and phonophobia. The fever reached 40°C orally. The headache waxed and waned; however, 1 day before admission she had an episode of vomiting in the morning. During the next 24 h the fever and headache persisted. On the day of admission her headache worsened, and she had five episodes of vomiting and a stiff neck.
On functional inquiry she had had no hallucinations or aura. She had no confusion, weakness or decreased alertness. There was no history of rash, upper respiratory tract infection or sinusitis. She had had no gastrointestinal or genitourinary complaints nor had she been sexually active. She had not been receiving antimicrobials. She had not ingested local food while in Mexico. Her immunizations were up to date. There was no exposure to animals. She had had prior surgery 6 months before admission for a dislocated toe. She had no prior history of primary or recurrent herpes simplex infections. She had a past history of occasional headaches which were easily relieved with ibuprofen.
The family had been in Mexico 4 days before the onset of her symptoms. The other family members were well. Her brother had developed a cold sore 1 week before her illness.
On admission her temperature was 38.5°C, respiratory rate was 18/min, pulse was 80/min and blood pressure was 114/50 mm Hg. She looked unwell but not toxic. She was ambulating, cooperative and oriented. Head and neck examination was normal. She had meningismus and a positive Brudzinski sign. There was no papilledema on funduscopic examination. A systolic flow murmur was heard at the left sternal border.
Initial laboratory investigations included a complete blood count which showed a white blood cell count of 12. l × 109/l with 9.5 × l09/l neutrophils and monocytes of 1.16 × 109/l. Hemoglobin was 116 g/l, and platelets were 203 × 109/l. Serum electrolytes were normal. Urinalysis was negative for nitrites and red and white blood cells. The cerebrospinal fluid was turbid with a white blood cell count of 2200 × 106/l with 65% neutrophils and a red blood cell count of 99 × 106/l. A Gram-stained smear was negative for bacteria. The cerebrospinal fluid protein was elevated at 2.99 g/l and the glucose was 2.5 mmol/l. Computerized tomography scan of the head without contrast was normal. Blood, urine, stool and throat swab cultures were negative. A chest radiograph was normal.
A presumptive diagnosis of bacterial meningitis was made, and the patient was treated with ceftriaxone and vancomycin. During the next 72 h the fever persisted, although the patient reported feeling that her headache was somewhat improved. Aerobic cultures were negative at 48 h. She had new onset of night sweats on the evening of the third day of hospitalization. At 72 h the microbiology laboratory reported a very light growth of Gram-negative bacilli from one (thioglycolate) of four enrichment broths incubated anaerobically (Fig. 1).