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Case 1 Presentation
A 15-year-old boy presents with a 12-hour history of progressive confusion, slurred speech, and ataxia. He was seen earlier in the week for rhinorrhea, cough, and fever and was diagnosed as having a viral illness. His symptoms improved until 12 hours before presentation when he became moody, confused, and ataxic. He denies any weakness, headache, diarrhea, constipation, visual changes, neck stiffness, photophobia, or phonophobia. He also denies any toxic ingestions and drug or alcohol use. He has not had any immunizations recently.
He weighs 126.3 kg, and his vital signs are as follows: heart rate, 96 beats per minute; blood pressure, 121/80 mm Hg; respiratory rate, 16 breaths per minutes; oxygen saturation, 99% on room air; and temperature, 37°C. He is awake although somnolent, requiring frequent prompting to answer questions. His sensations are normal, and strength is 5/5 in all extremities. Deep tendon reflexes are absent in the lower extremities, with down-going plantar responses. He is unable to support himself in a sitting or standing position. Rapid alternative movements are slow and deliberate without obvious dysmetria. Findings on the remainder of the neurologic and the cardiac, respiratory, abdominal, genitourinary, and rectal examinations are normal.
The result of a noncontrast head computed tomography (CT) is normal. Cerebrospinal fluid (CSF) analysis reveals 5 red blood cells, 600 white blood cells (WBCs) (87% lymphocytes), and normal levels of protein and glucose. The results of polymerase chain reaction tests on CSF for herpes simplex virus, varicella zoster virus (VZV), Epstein-Barr virus (EBV), cytomegalovirus, human herpes virus 6, and adenovirus are negative. The result of nasopharyngeal washing is negative for influenza A and B. A further study elucidates the diagnosis.
Case 2 Presentation
A 14-year-old girl with attention-deficit/hyperactivity disorder (ADHD), not currently taking any medications, is referred to the emergency department (ED) to rule out type 1 diabetes …
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