Red Book Online Presents: Diagnosis Detective | July 2025
Editor: Kristina A. Bryant, MD, FAAP
Case contributed by Maria Bonilla, BS; Danielle Daniels, MD, FAAP, Peds Infectious Disease, State University of New York (SUNY) Upstate Medical University
An 18-month-old unvaccinated child presents with fever, nasal congestion and decreased oral intake for 2 days. She is brought to the emergency department, where she tests positive for rhinovirus/enterovirus and is discharged home with supportive care instructions. On day 4 of illness, her symptoms worsen with persistent fever, lethargy, vomiting, and an unwillingness to move her neck. She returns to the emergency department where she is found to have a rectal temperature of 40.5o C. On exam, she is lethargic and difficult to arouse. Attempts to move her neck result in moaning with whimpering. A lumbar puncture is performed and reveals pleocytosis with the following gram stain from the cerebrospinal fluid:
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