To describe an unusual case of Neisseria meningitidis meningitis presenting with early bilateral hearing loss, delayed onset of fever, and subsequent embolic strokes due to new onset atrial fibrillation, emphasizing the importance of high clinical suspicion in atypical neuro-infectious presentations.

A 54-year-old man with well-controlled HIV (CD4 > 500), diabetes mellitus, hyperlipidemia, and remote colon cancer presented with altered mental status. While in the ED, stroke code was activated and he was found to have receptive aphasia, and bilateral hearing loss but no fever. His NIHSS was 4 for confusion and aphasia. Initial stroke workup including brain imaging was unremarkable; labs showed leukocytosis and thrombocytopenia. TTE showed normal ejection fraction with a mildly dilated left atrium. Neck stiffness accompanied with fever developed later, prompting lumbar puncture confirming Neisseria meningitidis meningitis. MRI brain later revealed embolic infarcts, and his course was further complicated by new-onset atrial fibrillation. Given new onset infection, TEE was later obtained showing no PFO/ASD and no concern for endocarditis. He completed ceftriaxone therapy with full recovery to neurologic baseline and was started on anticoagulation for secondary stroke prevention.