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An 11 year old girl was brought to Saint Elsewhere Medical Center ER because of fever and headache for two days. She developed focal seizures and slipped into a coma. The family just came from an 11 days trip to the Smokey Mountains in Tennessee. She did not have any history of insect or tick bite, wild animal exposure, or had any upper respiratory tract symptoms. They drank from mountain stream water which was filtered. No other members of the family got ill. On arrival at the ER, her temperature was 102.6 F (39.2 C) and a Coma Glasgow score of 6 to 7. There were no rashes. Her deep tendon reflexes were hyperactive with both ankle clonus. Other physical examination were all normal. CT of the head showed edema of the brain. Her CBC showed WBC of 19,000.(5,000 to 12,000 normal range). Spinal tap was not done because of fear of herniation from increased intracranial pressure. The brain wave showed generalized slowing. Leo Leonidas, MD, FAAP, Assistant Clinical Professor in Pediatrics, Tufts University School of Medicine, Boston; Attending Pediatrician, Eastern Maine Medical Center, Bangor, Maine.
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