Meningitis (pediatrics) Quiz: Ace Your Exams

A 4-year-old boy is brought to the emergency department by his parents for evaluation of 3-days of fever and irritability following an upper respiratory tract infection that started one week ago. His parents note a persistent runny nose and cough that began one week ago and has been improving. Today the patient developed a fever reaching 38.7°C (101.7°F) and the patient exhibited decreased activity and increased sleepiness. The patient's vaccinations are up-to-date. Temperature is 38.5°C (101.3°F), heart rate is 112/min, respiratory rate is 24/min, blood pressure is 92/62 mmHg, and oxygen saturation is 97% on room air. Physical examination reveals a pale, lethargic child who is responsive to voice. He has clear fluid from the nares bilaterally without purulent discharge and several oral ulcers. Neck stiffness and photophobia are present without evidence of papilledema or focal neurological deficits. Bloodwork shows normal white blood cell count, elevated C-reactive protein (CRP), and normal procalcitonin. The patient undergoes lumbar puncture without complications and empiric antibiotics are started. Which of the following findings is most likely to be seen on cerebrospinal fluid (CSF) analysis?