Case history

A 4-year-old girl presented with lethargy and anorexia, increasing in severity over the last few days. The child had been complaining of generalised joint pains and felt unable to move her neck. Also she complained of episodes of blurred vision, headaches and her mother reported a new onset squint. On further questioning, her mother said she had a circular rash on her forehead about 6 weeks previously, which had self-resolved.

On examination, all observations were stable. She was irritable with restricted neck movement, neck stiffness and photosensitivity. Her pupils were equal and reactive but there was bilateral papilloedema and horizontal nystagmus on right lateral gaze. There was an obvious difficulty in left abducens function. The rest of the examination was unremarkable.

An MRI was performed (figure 1). A lumbar puncture (LP) microscopy showed WC5 RC <1; no organisms seen. Blood cultures were negative.

Questions

1. From the MRI (figure 1), what does the image …