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 ).