Case 1: 60 year old man with fever, nausea/vomiting and diarrhea. Over 5 days he developed progressive upper extremity weakness, upper trunk ataxia, and respiratory failure. He was transferred to us after intubation. Lab Na 112, ALT 394, AST 588. CK peaked at 4494. Brain, and spinal MRI were negative. CSF glucose 83, protein 80, WBC 47, encephalitis panel negative. Exam showed primarily upper extremity weakness and normal deep tendon reflexes. There were no extra ocular muscle or pupillary abnormality. He was empirically treated with Botulism antitoxin and myasthenia panel was sent. Patient eventually improved and extubated after one week on ventilator. Later CSF WestNile antibodies showed IgM+, IgG-, confirming WestNile infection as the etiology.

Case 2: 71 year old man with acute ataxia. Patient awoke one day with difficulty walking, swallowing, and slurred speech. He mowed the lawn with no issues the day before. On exam he was profoundly ataxic, was unable to sit up without holding on to bed rails. Brain MRI showed small hygroma bilaterally. A large work up was planned to check for broad differential diagnoses. On day 2 of admission, a large engorged tick was found under right axilla during assisted bath, which was removed. Patient improved from 2 person assist to contact guard assist on discharge.