Mark Crislip, MD


February 10, 2012

Clinical Presentation

A 27-year-old, white man presents with altered mental status and agitation.

History and Physical Examination

History. The patient's illness started with a nonspecific fever to 102o F that was accompanied by a mild headache and myalgias. He felt ill enough to stay home from work but not ill enough to seek healthcare, crediting the fever to "what was going around" that August. He improved and his fever resolved the week before admission in early September, when he became agitated, violent, and confused. He was brought to the emergency room and required 4-point restraints and sedation, followed by intubation. He had no new symptoms in the day preceding the onset of agitation.

History revealed the following:

  • Medical history: none

  • Medications: none

  • Allergies: none

  • Habits: drinks on weekends

  • Diet: regular

  • Travel: recent hiking trip to Eastern Oregon and the Cascades; he had returned to Portland 48 hours before the fevers started

  • Social: single, recently moved in with his girlfriend

  • Pets: 2 cats, belonging to his girlfriend

  • Immunizations: up to date

  • Sports/water exposure: drank stream water, swam in lakes while hiking; numerous mosquito bites

  • Infectious disease exposure: none known

Physical examination. On physician examination, the following were noted:

  • Vital signs: temperature: afebrile; pulse: 90 beats/min; respirations: 18 ventilator breaths/min; blood pressure: 118/78 mm Hg

  • General: not chronically ill

  • HEENT: scattered 1-2 cm lymph nodes, neck supple, endotracheal tube in place

  • Lungs: clear

  • Heart: normal, no murmurs, rubs, gallops

  • Abdomen: nontender; spleen tip possibly palpable

  • Extremities: normal

  • Skin: no rashes

  • Genitourinary: normal

  • Neurologic: moves extremities to pain only; not requiring sedation on ventilator, does not respond to voice

Diagnostic Evaluation

Lab results. The following results were obtained:

  • WBC: 5.8 x 103/mm3

  • Hgb: 14 g/dL

  • Differential: 68% polymorphonucleocytes; 22% lymphocytes

  • Basic metabolic panel: normal

  • Bilirubin: 0.9 mg/dL

  • Transaminases: normal

  • Urinalysis: normal

  • Drug screen: normal

Lumbar puncture

  • WBC: 30 x 103/mm3 with 69% lymphocytes, 28% monocytes, and 3 polymorphonucleocytes

  • Protein: 101 g/dL

  • Glucose: 86 mg/dL


  • Chest radiograph: normal

  • CT: normal


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.