A 9-year-old previously healthy boy presents to the emergency department (ED) in Honolulu, Hawaii, with fever and gait disturbance. He developed a frontal headache, daily tactile fevers, and bilateral calf pain with an unsteady gait 4 days before admission. He experienced 3 episodes of watery diarrhea on the day before admission. On the day of admission, he has continued need for assistance when walking due to unsteadiness, blurry vision, and back pain.

There is no history of altered mental status or recent travel or exposures. He lives with his mother, father, and 8 siblings, as well as a pet dog and rabbit. This is his first time experiencing these symptoms.

On physical examination he is febrile (temperature, 106°F [41.1°C]), with a heart rate of 104 beats/min, a respiratory rate of 20 breaths/min, blood pressure of 103/65 mm Hg, and oxygen saturation of 100% on room air. He appears tired and...

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