Examination and Investigations
Upon admission, he was disoriented; his vital signs were as follows: body temperature, 38.1°C; heart rate, 100/min; blood pressure, 168/98 mmHg; and respiratory rate, 16/min. He had signs of nuchal rigidity. He had no anisocoria, intact light reflexes, and no pain on sinus tapping. Other physical examination findings were normal. Laboratory findings on admission were as follows (Table 1): white blood cells, 16,200/µL; hemoglobin, 17.3 g/dL; and platelets, 4.6×104/µL. Liver enzyme levels were elevated: aspartate aminotransferase, 123 IU/L and alanine aminotransferase, 114 IU/L. Renal function was also exacerbated: blood urea nitrogen, 28.1 mg/dL and creatinine, 1.23 mg/dL. The C-reactive protein level and erythrocyte sedimentation rate were 24.1 mg/L and 17 mm/h, respectively. Anti-HIV antibodies were absent, and the HbA1c level was 7.3%.
Head computed tomography showed no evidence of brain herniation. We identified positive signs of meningeal irritation and conducted a fluid test. Cerebrospinal fluid (CSF) had a cloudy appearance, and analysis revealed a pressure of 24 cm CSF, a cell count of 496 cells/µL (84% neutrophils and 16% lymphocytes), protein levels of 417 mg/dL, and sugar levels of 1 mg/dL. Gram staining on the CSF revealed gram-positive cocci.