Seen in the ED: Fever, Joint Pain, and Positive Jolt Sign in a Young Man

Patient history. A 32-year-old man presents to the emergency department (ED) for one day of fever up to 103.5°F and joint pains affecting both knees and both ankles. He is also having a generalized headache. About 2 weeks ago he was at this ED for dysuria that began approximately 5 days following unprotected sex with a new partner. Urinalysis was negative and he was treated with azithromycin and ceftriaxone, but the urine culture, chlamydia, and gonococcal (GC) tests were all negative. He denies any vomiting, cough, sore throat, rash, or other complaints.

Vital signs & physical examination. Vital signs are normal except for an elevated temperature (100.4°F). Physical exam is normal except for slight pain when moving eyes side to side and a positive jolt sign. Examination of the knees and ankles and other joints is unremarkable.

Initial differential diagnosis:

• Viral syndrome
• Meningitis
• Disseminated GC
• HIV
• HSV

Initial diagnostic testing. CBC was completely normal but there was a high normal WBC and elevated PMN percentage. Results of basic metabolic panel were normal.

Herpes Meningitis from The Emergency Medicine 1-Minute Consult Pocketbook