Fever and stiff neck.

Clinical Presentation: An 11-month-old boy was seen in the emergency department by his pediatrician for evaluation of fever (body temperature, 38.5°C) and a stiff neck. The patient’s illness began 5 days earlier when he developed nasal congestion and fever. His pediatrician prescribed amoxicillin on the third day of illness. The fever persisted, however, and by the fifth day, the patient was irritable and refused to flex his neck. New symptoms reported in the emergency department included decreased activity, poor intake of food and fluids, and decreased urine output. The parents also reported that after 1 day of amoxicillin therapy, the patient developed a faint red rash over his trunk, arms, and legs. The rash faded after 2 days. Symptoms of confusion, headache, conjunctivitis, cough, vomiting, or diarrhea were denied; however, the parents reported that his usual “noisy breathing” seemed worse. Medical history included a diagnosis of laryngomalacia diagnosed by bronchoscopy at age 5 months. The infant was born at term after an uneventful pregnancy to a healthy mother. He attended a day care center while his parents worked. There was no exposure to cigarette smoke or pets. Immunizations were up-to-date, but he had not yet received pneumococcal vaccine.