A Recurrent Headache

Case Presentation A 43-year-old man presented to the emergency room in September 2004 with a two-day history of increasing headache, myalgias and low-grade fever. No family members had been ill recently and he denied having nausea or diarrhea. On examination, he was nontoxic, with a temperature of 37.5¡ãC, pulse of 90 beats/min and blood pressure of 146/84 mmHg. Skin rashes were not present, and the neck was supple. The patient claimed that he seldom had headaches but that he had been hospitalized in England 15 years ago for viral meningitis. He remembered receiving antibiotics at the time despite being told it was a viral meningitis. The patient underwent a computed tomography scan of the brain, which was normal, followed by a lumbar puncture. The opening pressure was not recorded, but there were 23x106/L polymorphonuclear cells and 308x106/L lymphocytes in the cerebrospinal fluid (CSF). The CSF protein was elevated at 1.26 g/L (N¡Ü0.45), with a CSF glucose of 2.9 mmol/L compared with a serum value of 5.3 mmol/L. The peripheral white blood cell count was 10.5x109/L, with 8.0x109/L neutrophils