blood cells and 2 red blood cells. Differential showed 14% neutrophils, 55% lymphocytes, 9% monocytes, and 18% eosinophils. The cerebrospinal fluid (CSF) glucose was 53, protein was 43.2, and Gram stain was negative for microorganisms. Blood culture was negative. Chest X ray and KUB (kidney, ureter, bladder) were normal. CT performed at the outlying regional medical center was negative for any acute intracranial process. HSV PCR (herpes simplex virus polymerase chain reaction) along with spinal fluid cultures were obtained and sent.The patient was initially started on intravenous (IV) ceftriaxone for bacterial coverage and acyclovir for possible herpetic meningoencephalitis. On the second day of admission, the patient experienced several simultaneous tonic/clonic seizures that resolved with IV phenytoin. MRI of the brain revealed a small area of infarction within the leftbasal ganglia and the right superior cerebellar hemisphere. The patient was started on oxycarbazepine for seizure prophylaxis. Immunoglobulin and complement titers were sent. On day 3 of admission, the patient awoke with severe lethargy, bilateral lowerextremity spasticity, right-eye ptosis, horizontal nystagmus, and gross left-sided hemiplegia. A repeat MRI demonstrated very large infarcts in the leftand right-basal ganglia and the right-temporal lobe not previously visualized. Blood cultures revealed no growth, and HSV PCR was found to be negative on the third day. Immunoglobulin titers revealed an immunoglobulin E of 9147 (normal, 0-230 U/mL). Immunoglobulins A, G, M, and complement C3, C4 were within normal limits. Out of concern for a fungal infectious etiology, the patient was immediately transferred to a tertiary intensive care unit for infectious disease consult. She was started on IV voriconazole. Further workup and repeat lumbar puncture demonstrated CSF that grew Coccidioides immitis, and antifungal therapy was switched to amphotericin B. The patient recovered well after a prolonged hospital stay and suffered minimal deficits Case ReportA 4-year-old female child was admitted on transfer from a regional medical center for symptoms of nausea, vomiting, dehydration, and complaints of headache and visual changes for approximately 4 days. Her symptoms had progressively worsened over time, and the patient was admitted for suspected meningitis. Past medical history was significant for recurrent upper respiratory infections as well as sinus and skin infections most notably eczema herpeticum. Previous metabolic and immunological workup for her symptoms was significant only for an elevated immunoglobulin E of 805 U/mL (normal 0-230 U/mL), and no definitive diagnosis was established at that time.Physical examination on admission revealed a well-developed, well-nourished female child within the 50th percentile of weight and 3rd percentile of height. Her temperature was 37.1°C; heart rate, 94 beats/min; respiratory rate, 18/min; and blood pressure, 116/76 mm Hg. The patient complained of photophobia on exam but denied any true nuchal rigidity, and ...