Case 2: Headache and Behavior Changes in an 11-year-old Boy

Presentation

An 11-year-old previously healthy boy presents with 2 days of eye pain, headache, slowed speech, and word-finding difficulty. One day before presentation he attended school and football practice without any noted behavior change, trauma, confusion, or coordination difficulty. On the day of presentation, he awoke with left-sided headache and decreased appetite. He appeared “dazed” and unable to answer basic questions and was brought to the emergency department. He had no fevers or recent illness. He had exposure to outside farm cats, mosquitoes, and stream water, but no exposure to lakes or swimming pools. He has no known history of tick exposure or ill contacts.

On physical examination, the patient is afebrile (99.7°F [37.6°C]) and appears uncomfortable. His heart rate is 80 beats/min; respiratory rate, 18 breaths/min; blood pressure, 108/55 mm Hg; and oxygen saturation, 98% in room air. When asked what time it is, he responds by asking an unrelated question (“How tall is it?”). His speech pattern is normal. There are no cranial nerve deficits or clonus observed. Slight pain is elicited with forward neck flexion. His balance and gait are intact, and his strength is equal bilaterally. Sharp optic disc margins are noted. Cardiorespiratory examination findings are normal, and no heart murmur is appreciated. Oral examination findings are normal. No cutaneous lesions are noted. …