A 10-year-old, previously healthy, Hispanic boy from El Salvador who had resided in the United States for 1 year was admitted to another hospital with sudden nocturnal onset of severe headache and vomiting. His medical history was negative for fever, accidental ingestions, head trauma, or seizure disorder. He did report having had chest pain and chest wall swelling while living in Central America, but these had resolved spontaneously.
Pertinent findings on physical examination included a body temperature of 38.1°C in an alert, well-nourished boy weighing 27.8 kg (25% percentile for age). Stiffness of the neck, but no other meningeal signs, prompted a lumbar puncture, which revealed a glucose level of 3.1 mmol/L, a protein level of 0.70 g/L, and white blood cell count of 60×106/L, with 0.90 lymphocytes. Bilateral dullness on chest percussion, with decreased breath sounds in both lung bases, was also present. Results of cardiac examination