Methods
The patient had elevated leukocytosis with no left shift. Atypical lymphocytes were detected. A mononucleosis screen (heterophile antibodies) test was positive. The glucose level was mildly elevated. Serum salicylate, alcohol, and acetaminophen levels were negative. His serum creatinine, creatinine kinase, and aldolase levels were elevated (Table 1 ). The urine drug screen test was negative (Table 2 ). A computed tomography (CT) scan without contrast of the head showed no intracranial abnormalities. He was treated empirically with piperacillin-tazobactam and intravenous fluid resuscitation before being transferred to the intensive care unit (ICU).
On the first day of arrival to the ICU, the patient remained sedated due to severe agitation. Piperacillin-tazobactam was switched to Ceftriaxone and Vancomycin, and Dexamethasone was added for suspected bacterial meningitis. Serum HIV, HSV, and Syphilis screen were negative. The patient tested positive for serum Epstein Barr Virus (EBV) Viral Capsid Antigen (VCA) IgG, EBV VCA IgM, and EBV Nuclear Antigen (EBNA) IgG. His serum creatinine kinase remained elevated (Table 1 ). Urinalysis was positive for blood and red blood cells (RBC) (Table 2 ). He received aggressive fluid hydration for rhabdomyolysis due to combative behavior and sedation.
The magnetic resonance imaging (MRI) of the head was normal, with no restricted diffusion in the diffusion-weighted image (DWI), and the apparent diffusion coefficient (ADC) map. The electroencephalography (EEG) only showed continued generalized slowed activity and absent post-dominant rhythm consistent with encephalopathy (Figure 1 ).
A lumbar puncture was performed to obtain cerebrospinal fluid (CSF) for analysis. The opening pressure was elevated, and the CSF was clear. CSF analysis demonstrated increased WBC with lymphocytes predominance, increased protein, and mildly increased glucose, which was consistent with aseptic meningitis (Table 3 ).