We discuss a case of a 36 yo otherwise healthy male who presented with altered mental status. The patient immigrated from India approximately 30 years ago but had since then been living in Toronto, Ontario. He had been vacationing with his family in New England near the region of Bar Harbor, Maine two days prior to admission, when he began experiencing fevers, headache, vomiting, malaise and altered mental status. He had no history of abscess, malignancy, splenectomy, or glucocorticoid therapy.
He was found to have fevers of up to 103F, normal head CT, transaminitis, and thrombocytopenia. Physical exam was notable for neck stiffness and localization to pain but absence of rash. Lab results were notable for HA1c of 11.9, suggesting uncontrolled diabetes as a risk factor for infection. Initial LP showed ~8,000 WBCs with 84% PMNs, glucose of 2, and protein count of 2,090.
An EVD shunt was placed for intracranial hypertension and he was intubated for airway protection. Empiric treatment was narrowed to a 7 day course of cefepime and intrathecal colomycin + gentamicin for improved antibiotic penetration, which was further narrowed to ceftriaxone. Patient was sedated in a pentobarbital coma and treated with therapeutic hypothermia.