During the month of August 2013, an 8-year-old previously healthy boy was transferred from Mexico to San Antonio, TX, after 5 days of headache, fever, and nausea with associated photophobia and altered mental status. The patient had been spending time in Mexico, where he used river water for bathing. The patient presented to the emergency department with respiratory distress. On examination, the patient had neck stiffness, a temperature of 99.1°F, a pulse of 113 beats/min, a blood pressure of 131/65 mm Hg, and a respiratory rate of 30 breaths/min. The Glasgow coma scale was 9. He subsequently became unresponsive and had to be intubated. A computed tomography (CT) scan of the head showed ventriculomegaly, and hence, a lumbar puncture was performed. The lumbar puncture revealed cloudy cerebrospinal fluid (CSF), with a total white cell (WBC) count of 2,185 cells/mm3 (90% neutrophils, 2% lymphocytes, and 8% monocytes), 3,000 red blood cells/mm3, and a total protein level of 311 mg/dl. The causative agent was detected by light microscopy with Wright Giemsa-stained cytocentrifuged smears of the CSF (Fig. 1). A CSF Gram stain revealed numerous WBCs and no bacteria. After consultation with a pathology resident and further review, the causative agent was noted in the Gram stain (Fig. 1, inset). The patient was started empirically on rifampin, amphotericin B, and azithromycin (see reference 1 in the answer to the photo quiz [doi:10.1128/JCM.00402-14]). The CSF was cultured using nonnutrient agar with an Escherichia coli overlay (xenic culture) (reference 2 in photo quiz answer [doi:10.1128/JCM.00402-14]). In addition, the CSF was inoculated into MRC5 cells supplemented with 5% fetal calf serum, generally used for viral culture. The causative agent grew rapidly in both cultures. An additional CSF specimen was sent to the CDC for PCR confirmation. Miltefosine was added to the treatment regimen after confirmation of the causative agent by PCR (reference 3 in photo quiz answer [doi:10.1128/JCM.00402-14]).
FIG 1.
Wright Giemsa-stained cytocentrifuged smear of CSF. The inset shows the Gram stain. Magnification, ×400.
(For answer and discussion, see page 1673 in this issue [doi:10.1128/JCM.00402-14].)