not-yet-known not-yet-known not-yet-known unknown Methods (investigation and treatment) On the first day of admission, the patient was conscious and oriented. He had a fever spike of 101 degrees Fahrenheit and three episodes of watery stool. Tachypnea was resolving, and he had a dry cough and diplopia that wasn’t present earlier in the day. His vitals and physical exam remained unchanged except for crepitations now audible over both lung fields. Fluid intake was 3650 milliliters, with an output of 1300 milliliters. Lab reports showed a hemoglobin of 14.5 g/dl, platelet count of 145,000/Cumm and 17% lymphocytes on DLC, and AST & ALT of 64 units/L and 43 units/L respectively. An anteroposterior chest radiograph (Fig 1) showed no abnormality and an ultrasound of the abdomen showed mild splenomegaly. The plan at this this included continuing current antibiotics for ten to fourteen days, and considering stepping up antibiotics if fever spikes persisted. Over the next 3 days our patient’s condition continued to deteriorate. Fever spikes continued, now up to 104 degrees Fahrenheit. The investigations corroborated the clinical picture; There was a decrease in the thrombocyte count by 22,000/Cumm and an increase in AST to 982 and ALT to 505 units/L. LDH was raised to 1343 units/L, raising concerns for HLH. Sub-specialty services were brought onto the case: Infectious disease concurred with the medical team’s management and pulmonary medicine recommended a step-up to the high dependency unit in light of reducing saturation. Having been admitted to the Intensive Care Unit on the evening of the 4th day in light of desaturation to 91% on ambient air. That night he also developed diplopia which for which neurology and ophthalmology opinions were sought. On the morning of the 5th day, neurology recommended an MRI that showed an area of restricted diffusion in the splenium of the corpus callosum (Fig 3.1 & 3.2) and a mild hyper-intense signal in the subcortical white matter of the right postcentral gyrus and centrum semiovale (Fig 4.1& 4.2). They opined that the findings were not clinically relevant and recommended a follow-up MRI after four weeks. Ophthalmology endorsed a normal fundic examination and recommended follow-up in their office. The CT scan done early that morning showed sub-segmental consolidation in both lower lobes with nodules in the bronchovascular interstitium with mediastinal adenopathy likely of infectious etiology (Fig 2). Meropenam was added to his anti-biotic regiment.. The sixth day saw a plateau in his condition, while the fever spikes and bicytopenia persisted, a less dramatic decline in the platelet count of only 3,000/Cumm, a small decline in leukocyte count from 7000/Cumm to 5000/Cumm with similar differentials, and, more reassuringly, a decline in the liver transaminase, down to 706 units/L and 630 units/L for AST and ALT respectively. Whereas, the cultures sent on the day of his admission grew Salmonella paratyphi A resistant to fluroqiunolones but sensitive to all other drugs, urine analysis showed 8-10 cells per HPF and urine positive for glucose, ketones, and protein. However, cultures grew no organisms likely due to antibiotic treatment received prior to admission. In light of the sensitivity reports meropenam was discontinued. The next 4 days saw an improvement in the patient’s clinical condition, with fewer spikes, now reaching a temperature of 100.5 degrees Fahrenheit, and persistent albeit lowered transaminitis with an AST of 222 units/L and an ALT of 365 units/L. In light of this improvement, the patient was shifted back to the ward, though azithromycin was added due to persistent fever spikes. The remainder of his hospital stay was uneventful, with the last documented fever spike being at 8 pm on the tenth day of his. His thrombocytopenia and transaminitis gradually began to normalize. And after repeated requests from the patient and his family, he was discharged on the eleventh day.