Clinical reasoning: a 35-year-old man with 2 episodes of meningoencephalitis associated with flu-like illnesses.

SECTION 1 A 33-year-old man with an unremarkable medical history presented to an outside hospital emergency department (ED) in January 2011 with altered mental status and a seizure. Four days prior to his admission, his children experienced fevers and body aches that self-resolved. The patient developed similar symptoms 3 days later that he treated with acetaminophen and ibuprofen. On the morning of admission, he became disoriented and unable to answer simple questions. Paramedics were called, and he had a witnessed generalized tonic-clonic seizure on their arrival. He had a second witnessed generalized seizure in the ED and was intubated for airway protection. CT of the brain had normal results. CSF analysis revealed 7 leukocytes/mL (62% lymphocytes), 41 erythrocytes/mL, glucose 69 mg/dL, and protein 83 mg/dL. CSF Gram stain and bacterial cultures were negative. MRI of the brain with and without contrast and magnetic resonance angiography of the brain had normal results. EEG done while the patient was intubated showed nonspecific diffuse slowing and sedative changes but no epileptiform activity. Herpes simplex virus (HSV) PCR was negative. He was placed on empiric ceftriaxone, vancomycin, and acyclovir. He was extubated and slowly returned to normal within 3 days. He was discharged on hospital day 4 on phenytoin.