I had written earlier about the 3 month old with the bulging fontanelle - here's what happened... She got a head CT prior to tap - I checked with 2 neurology attendings on this one - the reasoning was that if the increased ICP was being caused by say a frontal bleed or some type of mass, then the asymetrical force could cause herniation with a tap, where as the diffusely increased ICP was less likely to do so. Result - negative. There was some extra axial fluid to the right of midline but that was interpreted as normal for age. And yes, her brains were protruding through her fontanelle and yes her sutures were open. Labs - ordered CBC, diff, plts, glucose, renals, bcx, cath ua & cx. results: WBC 14.4, H&H 9.9/29.2, plts 275, Diff % N 67 L26 M 7 B 0 E0, gluc100, BUN & creat 10, <0.3 BCX drawn - no organisms on gram stain, and I didn't follow up on the ER intern in time and the cath UA/cx wasn't done before abx were started. The tap: 2 tries by the intern yielded blood and no spinal fluid. Peds team came and got the tap. Tubes were cloudy, orange Tube 1 nuc cells 100, rbcs > 10k, N 44, L 52, B 0, E 0, M 4 Tube 4 nuc cells 90 , rbcs >10k, N52, L 38, B0, E 0, M 10 Tube 2 glucose 49, protein 97 Tube 3 held Gram stain - no organisms seen I started her on Ceftriaxone and Vancomycin but did not use dexamethasone. She improved remarkably by the next day and according to Grandma was almost her old self by the following day - at that point her fontanelle was softer and not as high. She was discharged at day 3 when CSF and Blood cx were neg x3. I didn't actually get to see her before discharge but I heard she was acting like her old self. As I've mentioned this case to other docs I have heard a number of stories about this type of presentation of bulging fontanelle - with fever, with viral illness, even attributed to periods of rapid brain growth. Thanks to all who emailed privately! Gail Gail S. Hertz, MD, IBCLC Resident, Dept. of Pediatrics PSGHS Children's Hospital Hershey PA