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A 19-year-old woman had a 1-week history of gradual onset headache, vomiting, double vision and unsteadiness. She had been previously well. She had no sick contacts and her last foreign travel had been to Nepal over 5 years before. She was febrile at 38.4°C but systemic examination was otherwise normal. She had an ataxic gait, left sixth and seventh cranial nerve palsies, brisk lower limb reflexes and right ankle clonus.