![]() Neurologically, she was altered and had positive Brudzinski and Kernig signs. She was tachycardic with 2+ distal pulses bilaterally and a brisk capillary refill. Physical exam was otherwise significant for a normocephalic and atraumatic head, sunken eyes, and dry mucosal membranes. She was not answering questions but would respond “ow” and “nothing is helping” to painful stimuli. On physical examination, she was awake, ill-appearing, but not toxic. On presentation to the ED, her vital signs were as follows: temperature 99.5☏ heart rate 135 beats/min respiratory rate 24 breaths/min blood pressure 71/52 mm Hg oxygen saturation was 99% on room air weight was 20.4 kg. The patient’s immunizations were up to date. There were no reported sick contacts, allergies, recent travel, or new exposures. ![]() She attended school and lived with her parents, aunt, and grandmother. Her family history was reviewed and was non-contributory. The patient had no previous hospitalizations and was otherwise a healthy child. Parents denied any rashes, vision changes, vomiting, or diarrhea. The night before her ED presentation, her mother was extremely concerned when the patient could not remember her name or her parents’ names. In the days following, she became increasingly too weak to get out of bed, was intermittently confused, refused to answer questions, and was more lethargic. She was discharged home when her influenza, streptococcal throat swab, chest x-ray, and urinalysis were all unremarkable. ![]() The patient’s mother took her to a local hospital 4 days prior to her ED presentation with complaints of fever (maximum temperature 104☏), headache, and neck pain. She was able to tolerate water but her overall oral intake was diminished with a marked decrease in urine output, worsening to once daily. Her mother reports that she was in her usual state of health until 1 week prior to presentation when she developed low grade fevers and abdominal pain with associated complaints of headaches, neck pain, and muscle aches. A 5-year-old female with no significant past medical history presented to the emergency department (ED) in 2016 with altered mental status, decreased activity, fever, and decreased oral intake.
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