Image of the Week: Irritability and Lethargy in an Infant

An 11-month-old boy with a 2-day history of irritability and lethargy is brought to the emergency department by his mother. She reports that he has vomited 4 times today and has had fewer wet diapers than usual. He is up-to-date with his vaccinations. On examination he is febrile, and a slight bulging of his anterior fontanel and neck stiffness are noted. Laboratory tests demonstrate a serum glucose of 75 mg/dL. Blood cultures are ordered and lumbar puncture is performed. Analysis of the cerebrospinal fluid reveals a predominance of neutrophils.

Which additional finding in the cerebrospinal fluid is most likely?

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