Case 4: Frontal Headache, Photophobia, Fever and Vomiting in a 10-year-old Girl.

1. Maria Joao Vieira, MD* 2. Liliana Branco, MD* 3. Ana Luisa Lobo, MD* 4. Sergio Caselhos, MD† 1. *Servico Pediatria and 2. †Servico Otorrinolaringologia, Hospital da Senhora da Oliveira Guimaraes, Portugal A 10-year-old girl presents to the emergency department with a 12-hour history of frontal headache, photophobia, fever, and vomiting. She also has yellow nasal discharge. She was hospitalized and treated for pneumococcal meningitis 3 years ago. There is no history of head trauma, family history of immunodeficiency, or other repetitive infections. Her vital signs are as follows: temperature, 100.4°F (38.0°C); blood pressure, 118/81 mm Hg; pulse, 100 beats/min; and respiratory rate, 30 breaths/min. On physical examination she is covering her eyes and complaining of intense headache, and her speech is incoherent. Kernig and Brudzinski signs are positive. The results of fundus examination and the remaining neurologic examination are normal. Laboratory evaluation reveals a hemoglobin level of 12.3 g/dL (123.0 g/L); platelet count, 231×103/μL (231×109/L); white blood cell (WBC) count, 26.4×103/μL (26.4×109/L) (92% neutrophils); and C-reactive protein level, 48.2 mg/L (459.1 nmol/L). A head computed tomographic (CT) scan shows evidence of frontal, ethmoidal, and maxillary sinusitis, without any intracranial extension. A lumbar puncture reveals turbid cerebral spinal fluid (CSF) with pleocytosis (WBC count, 14,750/μL [14.8×109/L], with 96% neutrophils) and a markedly decreased glucose level (<1 mg/dL [<0.06 mmol/L]). A CSF culture was …