A 23-year-old woman presented with severe headache, strabismus, and a remote history of tick bites. Initial cerebrospinal fluid (CSF) analysis revealed elevated opening pressure (32 cm H2O), high white cell count, and increased protein levels, suggestive of infectious or aseptic meningitis given history of being unvaccinated. Meningo-encephalitis CSF panel was negative. MRI demonstrated signal abnormalities in the splenium of the corpus callosum, extensive leptomeningeal enhancement, cranial nerve involvement, and extensive T2 hyperintense cord signal abnormality in the entire cervical-thoracic cord. Despite initial antibiotic therapy, her condition deteriorated with altered mentation and seizure-like activity, necessitating intubation.

She was treated with high-dose steroids and plasmapheresis were initiated, with a notable clinical response. Over the course of her hospitalization, repeat imaging showed gradual resolution of cranial nerve enhancement and improvement of spinal cord signal abnormalities. Post-hospitalization, she experienced significant deconditioning, generalized weakness, and vocal cord issues likely secondary to prolonged intubation.