An 81 year old man presents with fever, chills, rigors and myalgia for 3 days. He also complains of tremors in his hands, weakness of his lower limbs, and difficulty in walking for the same duration.

His family members noted progressive changes in his behaviour since a day ago. He had gone camping in South Dakota 2 weeks prior to the onset of these symptoms.

His medical history is significant for diabetes, atrial flutter and sick sinus syndrome for 30 years, with pacemaker implantation.

He drinks socially, is not on any recreational drugs, and is not sexually promiscuous.

Select Relevant Investigations
Lumbar Puncture


Appearance: clear
WBC: 24/mm3 (0-5)
Neutrophils: 81%
Protein: 68 mg/dL (18-58)
Glucose: 64 mg/dL (50-80)
Gram stain: negative; preliminary culture reports will be available in 24 hours.
Blood sent for CSF tests for varicella, herpes, syphilis, Epstein-Barr virus, Cytomegalovirus, and Cryptococcal antigens. Results pending.
MRI Spine & Brain


You recall that a cardiac pacemaker has been implanted in this patient, and realize that MRI is contraindicated.
CT Brain


No abnormalities detected.
Stool Cultures


Stool microscopy and antigen levels are negative for routine bacterial, viral and enteric parasites.
Stool cultures are sent for detection of antibodies of poliovirus. Reports will be available in 24 hours.

Select Relevant Management
IV Acyclovir
IV Dexamethasone
Immune Gamma Globulins