Clinical Reasoning: A 42-Year-Old Woman With Mysterious Monocytic Meningitis

A 42-year-old woman with a history of migraine headaches and no other significant past medical history presented with daily headaches, cervicalgia, and nausea over a period of 3 weeks. These headaches were similar in severity to those that she had previously experienced. Presumptive migraine treatment was administered and she was released home. Three days later, her symptoms worsened and she developed double vision, unsteady gait, and right-sided hearing loss. She reported no fever or weight loss. Residing in the upper Midwest, her leisure activities included hunting pheasant, deer, and duck, and she regularly cooked and ate wild game. She had traveled periodically to a southwestern state in the months prior to presentation. In the year preceding the current illness, she had experienced multiple tick bites and reported that she had Lyme disease as a teenager. © American Academy of Neurology.