CASE PRESENTATION
A previously healthy 33-year-old Japanese man presented to the emergency room with worsening headache, fever, and chills. CSF and blood samples were collected for culture due to suspected meningitis and bacteremia. The CSF was within normal limits, and the blood culture was negative. The patient’s symptoms were treated with oral acetaminophen (3000 mg/day), and he was kept under observation in the outpatient clinic. He was hospitalized 3 days later for a worsening headache and fever. On admission, he had a Glasgow Coma Scale of E4V5M6. His vital signs included body temperature, 38.4°C; pulse rate, 99 beats/min; blood pressure, 122/72 mmHg; and respiratory rate, 20 breaths/min. Physical examination revealed patchy lymph follicles on the posterior pharyngeal wall and a positive ocular globe compression sign, which was absent at the initial visit. All other meningeal signs, such as nuchal rigidity, jolt accentuation, and Kernig and Brudzinki signs, were negative. Blood tests revealed mild leukocytosis (11,200 cells/μL, normal range: 3,900–9,700 cells/μL) with an elevated neutrophil count (79%) and C-reactive protein level (0.37 mg/dL: normal range ≤0.3 mg/dL). CSF, obtained by repeat lumbar puncture (LP), was clear, with an elevated initial pressure (300 mm H2O), cell count (22 cells/hpf, monocytes: 18/22, 82%), and protein level (50 mg/dL). The CSF smear, Indian ink test, antimicrobial culture, and polymerase chain reaction (PCR) tests for varicella-zoster virus and herpes simplex virus were negative. The patient’s 4-year-old daughter was reported to have gastroenteritis. The patient was diagnosed with aseptic meningitis (probably caused by an enterovirus), based on family history and his physical and CSF findings. He was treated with intravenous acetaminophen. The intensity of the pain caused by the compression of the ocular globe decreased on day 10, his fever improved on day 15, and he was discharged on day 19. His symptoms did not recur after discharge.