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).