A 4-year-old girl is brought to the emergency department due to fever and lethargy. Her parents say she has been withdrawn and less playful over the last 2 weeks. She has also had several days of low-grade fever and headaches. Since yesterday morning, the patient has mostly slept and seems to be increasingly confused. She has no significant prior medical problems and is up to date with recommended vaccinations. Her grandfather, who is visiting the family from South Asia, is being evaluated for cough; otherwise, the patient has no sick contacts. The family has a pet cat. Temperature is 38 C (100.4 F). The patient is somnolent and responds to painful stimuli. There is resistance to passive neck flexion. Her right eye is deviated medially, and funduscopic examination reveals several ill-defined, raised, yellow-white nodules near the bilateral optic discs. CT scan of the head reveals basilar meningeal enhancement. Lumbar puncture is performed, and cerebrospinal fluid analysis results are as follows: Item 1 of 2 Which of the following is most likely to yield the diagnosis in this patient?

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Explanation: 11ec2b69_bfc7_693b_8f63_2b453b273a0c_MD0005_00 This patient likely has tuberculous meningitis, a highly fatal form of extrapulmonary tuberculosis (TB). Manifestations typically begin with 2-3 weeks of prodromal symptoms (eg, headache, low-grade fever, lassitude) followed by progressive signs of meningeal irritation (eg, nuchal rigidity, vomiting, confusion). Cranial nerve palsies, coma, and seizures may occur. Choroidal tubercles (yellow-white nodules near the optic disc) are often detected via funduscopic examination. Suspicion for tuberculous meningitis is typically raised when brain imaging reveals basilar meningeal enhancement and cerebrospinal fluid (CSF) examination shows the following: Elevated protein (>250 mg/dL, generally 100-500 mg/dL) Low glucose (<10 mg/dL) Lymphocytic pleocytosis Elevated adenosine deaminase Definitive diagnosis requires serial lumbar punctures with CSF examination for acid-fast bacilli using smear and culture. (Choice B) Cytomegalovirus can cause a mononucleosis-type syndrome with fever, malaise, and lymphadenopathy. Retinitis and encephalitis may occur but are rare in patients with intact immunity. This patient with basilar meningeal enhancement and choroidal tubercles likely has tuberculous meningitis. (Choice C) Cryptococcal meningitis can be diagnosed with India ink preparation of CSF. Although most cases occur in patients with advanced HIV, immunocompetent individuals can develop subacute meningitis from Cryptococcus in rare cases. Basilar meningeal enhancement is uncommon. (Choice D) Toxoplasmosis infection is usually asymptomatic in immunocompetent individuals, but it may occasionally cause a mild systemic illness. Encephalitis is rare and usually associated with multiple ring-enhancing lesions on brain imaging. (Choice E) West Nile virus can cause systemic symptoms and meningitis in children. However, manifestations are typically acute, retinitis is uncommon, and brain imaging does not usually reveal basilar meningeal enhancement. Educational objective: Tuberculous meningitis typically causes 2-3 weeks of prodromal symptoms followed by signs of meningeal irritation. Suspicion is often raised in patients with choroidal tubercles, basilar meningeal enhancement, and characteristic cerebrospinal fluid (CSF) findings. Diagnosis typically requires serial lumbar punctures with CSF examination for acid-fast bacilli using smear and culture.

A 4-Year-Old Girl Is Brought to the Emergency Department Due