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A 32-year-old, left-handed African woman presented with a 5 day history of increasingly severe headache, which was constant and worse on lying flat. During this period she also developed neck pain, projectile vomiting and visual blurring. In the previous 12 months she had taken holidays in South-East Asia, South Africa and Zambia. On examination she was alert and orientated. There was no meningism. Neurological examination revealed markedly reduced visual acuities of 6/36 in the right eye and 6/12 in the left eye. The visual fields were normal but she had bilateral papilloedema. The rest of the neurological examination, and the general examination, were normal.
What do you think was going on, and what would you do next?
Clinically, she clearly had raised intracranial pressure. Blood tests were not particularly helpful: the blood count showed 11.7×109/l white blood cells (neutrophils 6.9×109/l; lymphocytes 3.4×109/l) but was otherwise normal; erythrocyte sedimentation rate and C reactive protein were normal, as were renal and liver function tests; antineutrophil cytoplasmic antibodies, antinuclear antibodies and protein electrophoresis were also normal; screening for cytomegalovirus, Ebstein–Barr virus, herpes simplex virus, varicella zoster virus, measles, mumps, leptospirosis, tuberculosis and cryptococcus were negative. CT scanning of her head showed sulcal effacement and dilatation of the …
Competing interests None.
Patient consent Obtained.
Provenance and peer review Commissioned; not externally peer reviewed.