Clinical Case of the Month: A 49-Year-Old Man with Fever, Headache and Leg Weakness.

A 49-year-old man with an unremarkable past medical history presented to an outside hospital with a five-day history of fever, left leg weakness, myalgia and headache. The patient reported that the illness started as a fever and sore throat and he was originally diagnosed with streptococcal pharyngitis and prescribed antibiotics. The day after his initial diagnosis, his fever had progressed to include a headache, myalgia, a rash on his upper torso and right shoulder and sudden-onset left leg weakness with preserved sensation. With progressively worsening symptoms, he eventually presented to a local emergency department (ED), five days after his symptoms first started. He was experiencing continued left leg weakness, an inability to ambulate, persistent fevers to 103oF, muscle aches, an intense band-like headache and confusion. The patient denied neck stiffness, photophobia, loss of sensation or any additional muscle weakness. He denied any recent travel aside from work, any sick contacts, recent tick/insect bites, history of sexually transmitted diseases or contact with animals. He reported no history of illicit drug use as well as no recent weight loss, trauma or radiation exposure. The patient had approximately a 10-pack-year tobacco smoking history. For the last ten years he drank about a six-pack of beer daily while onshore (roughly two weeks out of every month). He works on an offshore oil platform. He was not taking any home medications besides his recently prescribed antibiotics. He lived alone at home in a moderately rural area of South Louisiana. His family history was non-contributory. A computed tomography (CT) scan of the head without contrast was unremarkable. A CT scan of his spine revealed degenerative disk disease of his lumbar region. A lumbar puncture (LP) performed at the outside hospital showed clear cerebrospinal fluid (CSF) with 343/cu mm of white blood cells (WBC; normal range: 0-5/cc mm) and 18cu mm of red blood cells (RBC; normal range: 0/cu mm); the WBC differential was 17 percent segmented neutrophils (normal range: 0-6 percent), 68 percent lymphocytes (normal range: 40-80 percent) and 15 percent monocytes (normal range: 15-45 percent). The CSF glucose and protein levels were 65mg/dL (normal range: 40-70mg/dL) and 151mg/dL (normal range: 15-40mg/dL), respectively. Additional CSF was sent to an outside lab for further work-up, including an Enterovirus panel, Herpes Simplex virus (HSV) and West Nile Virus (WNV). The patient was then transferred to our hospital for additional work-up and management.