Case presentation
A 17-year-old girl living in a village in western Nepal was taken to a tertiary hospital, Bir Hospital after being referred from another health center with chief complaints of fever for 17 days and altered sensorium of 4 days duration. She had a low-grade fever initially which got controlled partially with over-the-counter medication. The fever was insidious onset, gradually progressive but this time it was associated with headache, vomiting, and altered sensorium. She had no history of photophobia, ear discharge, convulsions, or focal neurological deficit. She was then taken to a nearby hospital from where she was referred to our hospital with a provisional diagnosis of meningitis. There was no similar history in the past and her family history was non-significant.
When she arrived at the emergency department of Bir Hospital, her axillary temperature was 101.2°F, pulse was 86/min and blood pressure was 140/100 mm Hg. The respirations were regular with a rate of 18 per minute and oxygen saturation was 96%. She had no eschar, rashes, or lymphadenopathy, pupils were normally responsive. The examination of respiratory system revealed normal vesicular sounds over both lungs without any added sounds. The cardiovascular examination was unremarkable.
On neurological examination, her Glasgow Coma Scale (GCS) was E3V4M6 (i.e. 13/15). She was drowsy and confused. Motor and sensory examination revealed normal findings, superficial and deep tendon reflexes were normal and bilateral planters were flexor. Cranial nerve examination revealed bilateral lateral rectus palsy (Figure 1 and 2), dysphagia, regurgitation of food on attempted feeding, dysarthria, and left sided upper motor neuron (UMN) type facial palsy (Figure 3).