Case 48: Aria, a 16-Year-Old Girl with Headache and Confusion

A 16-year-old previously healthy girl, Aria, presents to the emergency department (ED) with headache and confusion. While in triage, Aria has 2 episodes of emesis and several staring episodes. While being transported to a room, she has 20 seconds of convulsive movements that self-resolve, after which she is confused, sleepy, and does not recognize her parents. The ED physician obtains initial laboratory studies including a complete blood cell count (CBC) with differential, comprehensive metabolic panel, C-reactive protein (CRP) level, procalcitonin level, coagulation studies, urinalysis, urine drug screen, and pregnancy test. All of these studies are unremarkable. A blood culture is pending. A computed tomography (CT) scan of the head is performed, and the preliminary read is negative for any acute intracranial pathology. The ED physician gives Aria a dose each of acetaminophen and ondansetron, and due to concern for seizures, the physician also gives her a loading dose of levetiracetam. She also starts Aria on a continuous electroencephalogram (EEG). In the intervening 2 hours, Aria has not returned to her baseline neurologic status. The ED physician calls you to request admission for further evaluation and monitoring.