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Headache, fever and back pain in a 16-year-old boy.

CASE PRESENTATIONA previously healthy 16-year-old boy of East Indian origin wasadmitted to the Stollery Children’s Hospital (SCH) inEdmonton, Alberta in February 2003 for evaluation ofheadache and back pain. Lower back pain had started suddenlynine days earlier, after lifting weights, and had persisted. Athrobbing occipital headache started eight days before admis-sion. The patient thought he had possibly been febrile.There was no known exposure to tuberculosis and no historyof ill contacts. There had been recent travel to California andvisitors from India had been staying in the home. The boy hadalways lived in Canada.One day before admission to the SCH, the boy was evaluatedin a regional hospital because of worsening headache and backpain. Temperature was 38°C, pulse was 84 beats/min, respira-tory rate was 18 breaths/min and blood pressure was 120/80 mmHg.Physical examination revealed a coherent boy in mild dis-tress. He vomited for the first time during the assessment. Hisneck was stiff and a positive Brudzinski sign was present.Fundoscopy was normal. Tympanic membranes, mouth andthroat were normal. No significant lymphadenopathy was not-ed. Chest, cardiac and abdominal examinations were unre-markable. Cranial nerves, sensation, tone, power, coordinationand deep tendon reflexes were normal. On examination of themuskuloskeletal system, there was slight tenderness over thespinus processes of the third and fourth lumbar vertebrae (L3 and L4).A noncontrast brain computerized tomography scan wasnormal. Examination of cerebrospinal fluid (CSF) revealed awhite blood cell count of 6.1 × 10