Some spelling "B" ! A boy, his brother, and their "bug"

Today is a typically hectic late-summer day on the pediatric service at your tertiary care medical center. Amid the bustle, you've gotten a page from the emergency room to see a 5-year-old boy who has a fever and is complaining of left flank pain. When you enter the examining room, the patient is lying in bed, resting. He looks flushed and is slightly diaphoretic.

His mother tells you that her son had been healthy until two weeks ago, when he developed an intermittent low-grade fever for one week that was associated with vomiting, diarrhea, and fatigue. She assumed it was a "stomach bug" similar to an illness that had already resolved in his 7-year-old brother.

After that week, the gastrointestinal symptoms subsided but the boy began complaining of a stiff neck. His primary care pediatrician referred him to this emergency department with a concern of meningitis. The boy at no time complained of upper respiratory symptoms, sore throat, or abdominal pain.

Fatigue and lost appetite, so it's back to the ED

The boy's condition improved for two days; then the low-grade fever recurred and shortly reached as high as 103° F orally. Earlier today, he was brought back to his primary care pediatrician. His mother reported that he continued to be fatigued and had little interest in food. Headache and neck pain had become worse, but without restriction of neck movement. He had had an episode of loose, watery stool yesterday, after which he complained of left lower flank pain. There had been no change in urination or complaint of dysuria. The physician sent the patient back to your ED for evaluation and treatment.

On further questioning, you learn that the patient has no cough, rhinorrhea, or congestion. He has no rash or new insect bites, and no joint pain. His mother tells you she noticed that his fevers came on in the evening and were associated with chills and some diaphoresis. He is tolerating some food but his appetite is still poor.

The medical history is unremarkable; your patient was in good health until this illness. Immunizations are up to date; he has had no hospitalizations, allergies, or surgery. The birth and developmental history are unremarkable.

The family medical history is significant for respiratory illness in his older brother, who was hospitalized one year ago, during the summer, with pneumonia and a pleural effusion that required decortication. The pneumonia responded to ceftriaxone, and the brother has since been healthy. As you've already been told, that brother recently had a "stomach bug" but recovered and had no other illness. A 3-½-year-old sister is healthy. The mother is in good health but reports that she had epiglottitis as a child that required emergency tracheotomy, and she has seasonal allergies. His father is in good health. The patient and his family live in a suburban neighborhood. The children spend much of their time in the basement of their home, where a dehumidifier runs constantly but is cleaned daily. The family also has a covered fish tank.

You question the mother about the boy's travel history. Two weeks ago, she explains, the family took a camping trip in a mobile home to Niagara Falls, N.Y. There, the patient and his brother first felt ill, complaining of stomach pain. Afterwards, the family attended a family reunion and picnic in Connecticut. The mother reports that other children at the picnic were later found to be ill with Coxsackievirus but that her boys did not interact with the others because they were already feeling ill. They did not eat any of the food at the picnic, and their visit was "short."