An 18-year-old woman comes to the emergency department due to 3 days of worsening fever, headache, and neck pain. She lives in Boston, Massachusetts. She is employed as a barista and is sexually active with one partner. Temperature is 39.1 C (102.4 F). The patient is alert and conversational but appears uncomfortable. Photophobia and mild nuchal rigidity are present. There is generalized adenopathy in the cervical, axillary, and inguinal areas. A diffuse maculopapular rash is seen over the chest, abdomen, and proximal extremities. Genital examination is normal. Cerebrospinal fluid results are as follows: PCR testing of the cerebrospinal fluid for enterovirus and herpes simplex virus is negative. Which of the following organisms is the most likely cause of this patient's symptoms?

Question

An 18-year-old woman comes to the emergency department due to 3 days of worsening fever, headache, and neck pain.  She lives in Boston, Massachusetts.  She is employed as a barista and is sexually active with one partner.  Temperature is 39.1 C (102.4 F).  The patient is alert and conversational but appears uncomfortable.  Photophobia and mild nuchal rigidity are present.  There is generalized adenopathy in the cervical, axillary, and inguinal areas.  A diffuse maculopapular rash is seen over the chest, abdomen, and proximal extremities.  Genital examination is normal.  Cerebrospinal fluid results are as follows:  PCR testing of the cerebrospinal fluid for enterovirus and herpes simplex virus is negative.  Which of the following organisms is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d6ba_dd40_bc81_13485b86245e_MD0003_00 This patient's acute fever, headache, nuchal rigidity, and photophobia raise suspicion for meningitis. Subsequent cerebrospinal fluid analysis reveals lymphocytosis, mildly elevated protein, and normal glucose, indicating likely aseptic (viral) meningitis. Although the most common cause of aseptic meningitis (particularly in those with maculopapular rash) is enterovirus, this patient's negative enterovirus PCR makes this diagnosis unlikely. Another common cause of aseptic meningitis in young, sexually active adults is acute HIV infection. This syndrome typically occurs 2-4 weeks after transmission and often includes transient unexplained fever, generalized lymphadenopathy, and maculopapular rash. Approximately 25% of patients with acute HIV have aseptic meningitis, but symptoms are often mild. Although HIV infection is most common in high-risk groups (eg, intravenous drug users, individuals with multiple sexual partners), physicians should have a low threshold for HIV testing in sexually active individuals because patients may not be fully aware of their risk of exposure (eg, non-monogamous sexual partner) or may not be completely forthright about their social history. (Choice A) Lyme disease, a spirochetal infection caused by Borrelia burgdorferi, is endemic in Massachusetts. Early disseminated disease is often associated with lymphocytic-predominant aseptic meningitis. However, the rash of Lyme disease is an annular lesion that slowly spreads outward with central clearing (erythema migrans), not a maculopapular rash. erythema migrans (Choice B) Cryptococcal meningitis occurs primarily in patients with AIDS who have CD4 counts <100/mm³. Although patients with acute HIV can sometimes develop signs of significant immunocompromise (eg, oropharyngeal thrush), it is unusual to have cryptococcus during this period. Furthermore, cryptococcal meningitis is typically associated with cerebrospinal fluid evidence of low glucose and high protein. (Choice D) Tuberculous meningitis generally presents with several weeks of prodromal symptoms and progressive neurologic decline. In addition, CSF analysis typically shows low glucose (<45 mg/dL) and mildly elevated protein. (Choice E) Although meningococcal meningitis can cause a maculopapular rash early in the disease course, it generally evolves into petechiae. Furthermore, most cases progress rapidly over hours and lead to septic shock. In addition, cerebrospinal fluid would reveal a bacterial picture of low glucose, elevated protein, and a markedly elevated white blood cell count with neutrophil predominance. Educational objective: Acute HIV infection often causes unexplained fever, maculopapular rash, and aseptic meningitis. It should be suspected in sexually active or high-risk patients when more common causes of these symptoms have been excluded.

An 18-Year-Old Woman Comes to the Emergency Department Due to 3