History of Present Illness A 54-year-old Thai psychiatrist noted the onset of right leg tingling with weakness on dorsiflexion of her right foot approximately one week prior to admission. She has a history of lumbar disc disease and these symptoms were similar to previous flares. She took prednisone without improvement, and over the next few days she also developed right arm numbness, tingling, and weakness. She was admitted to a local hospital where a head CT revealed a double cystic ring-enhancing lesion in the left parietal region. Her condition progressed with the onset of confusion and she was started on high dose corticosteroids. She was transferred to Johns Hopkins Hospital and subsequently underwent left parietal craniotomy with cystic mass excision. Past Medical History Lumbar disc disease Hypertension Nephrolithiasis Migraine headaches Social History She was born in Thailand and moved to the United States at the age of 28. She works as an psychiatrist, is married, and has four children. Her last visit to Thailand was two years ago. She denies alcohol, tobacco, or illicit drug use. Physical Examination Temperature was 35.5 C, pulse 80 bpm, respiratory rate 12 bpm, and blood pressure 125/65. General - appears well and in no distress. Skin - no rash or lesions. HEENT - poor dentition with molar cavities and erosions but no obvious abscess, no sinus tenderness with normal maxillary transillumination, tympanic membranes intact and not inflamed. Neck - supple without lymphadenopathy. Chest, heart, and abdomen were normal with no masses on breast examination. Extremities - without edema. Neuro - oriented, cranial nerves intact, decreased sensation to light touch right leg greater than right arm, distal weakness in right leg greater than right arm. White blood cell count 10,200/mm3 Hematocrit 47.9% Platelet count 333,000/mm3 Sodium 130 meq/L Copyright 1997, 1998, 1999, 2000 The Johns Hopkins University on behalf of its Division of Infectious Diseases. All rights reserved.