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A 15-year-old girl gave a 2-week history of worsening neck pain and headache. Three weeks before she had sustained minimal injury in a car accident. She took simple analgesics, suspecting that her symptoms were due to the road traffic accident. When her condition worsened, she presented to the emergency department. On examination, she was anxious and had neck stiffness but was generally well and apyrexial. Neurological examination was normal. She was admitted via the paediatric clinic for observation, analgesia and investigations. Her white cell count was 14 300×109/litre (4.0–11.0) with neutrophilia and serum C-reactive protein was >320 mg/l (<10). Spinal x-ray was normal. She was started on intravenous ceftriaxone and oral metronidazole.
She developed right periorbital oedema and photophobia (figure 1). On examination, her visual acuity was 6/6 bilaterally with right hemifacial oedema, right-sided ptosis and limited right eye movements. There was resistance on retropulsion and also dilatation of the superior episcleral vessels on the right eye (figure 2). Intraocular pressure was normal and optic discs healthy. Both pupils reacted sluggishly but there was no relative afferent pupillary defect.
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