Case report

A 28 year old woman presented to the accident and emergency department with tightness and twitching across the facial muscles, upwards rolling of the eyes with deviation of the head and gaze to the right, and stiffness of the neck muscles. The symptoms were associated with sweating and tachycardia at a rate of 130 beats/min. Further clinical examination and imaging were unremarkable. She had no history and no evidence of skin breaks or dental or ear infection. All the blood tests were normal, including the electrolytes, C reactive protein, and white cell count.

The patient had returned from Kenya four weeks previously, where she had been on a safari holiday. Before going to Kenya, she had had all the necessary vaccinations and had started taking Malarone (proguanil with atovaquone) for malaria prophylaxis.

Ten days before her presentation, she had had colicky left flank pain with nausea and vomiting. Her general practitioner prescribed trimethoprim followed by ciprofloxacin for a presumed urinary tract infection. She …