An 18-year-old man was transferred from an outside hospital for evaluation of recent headache, fevers, and laboratory abnormalities.

The patient had a past medical history significant for attention deficit hyperactivity disorder (ADHD) and had presented to an outside hospital with complaints of fatigue, fever, and headache. He described the headache as frontal, severe, and stabbing in nature without associated neck stiffness, photophobia, or phonophobia. He also reported fevers to 105ºF. He was evaluated one day after the onset of symptoms at a local emergency room where a lumbar puncture was performed. By report of the patient and his mother, the lumbar puncture was negative and he was given a prescription for ketorolac for his headache. The patient went home and continued to have fevers and headache for which he was taking acetaminophen and ketorolac. Two days after his initial discharge from the emergency room he presented to another hospital complaining of sharp epigastric pain without radiation in addition to the headache and fevers. He denied nausea, vomiting, or melena. Laboratory data at that time revealed a creatinine of 4.6 and mildly elevated transaminases and the patient was transferred to this hospital for further evaluation and management.