CASE DESCRIPTION

A 45-year-old Jordanian man had 2 weeks of gradual onset headache, neck stiffness and loss of vision. The headache was occipital with pulsatile tinnitus and exacerbated by coughing, sneezing and bending forwards. Two weeks before the headache onset, he had developed mildly painful ulcers in his mouth but not elsewhere.

There had been no prodromal features, rashes, tick/animal bites and no history in the previous year of foreign travel or of risky sexual behaviour, and no connective tissue or ‘B’ symptoms. He had lived in the UK for over a decade and rarely visited Jordan.

He had experienced weekly tension-type headaches for years, and 26 years before, he developed an unprovoked deep vein thrombosis. His regular medications included amitriptyline, mebeverine, lansoprazole and ranitidine, but he took no antibiotics and no over-the-counter analgesia, vitamins or supplements.

On examination, there were no mouth or genital ulcers. His visual acuity, colour vision and eye movements were normal but detailed ophthalmological assessment identified bilateral disc swelling with an enlarged blind spot; optical coherence tomography showed a thickened retinal nerve fibre layer, greater on the right (figure 1). The remaining neurological examination, vital signs and routine blood tests were normal. CT scan of head showed bilateral optic nerve tortuosity and an empty sella, suggesting intracranial hypertension (ICH).