Another MRI was performed, and now showed bilateral subdural effusions. The second working diagnosis was basal tuberculous meningitis and treatment with a antituberculous regimen was started. Six days later a repeat lumbar puncture showed 60 cells per mm 3 and raised lactate. The first working diagnosis was encephalomyelitis and steroids were given. She had a right abducens palsy and pachymeningeal gadolinium enhancement on magnetic resonance imaging (MRI). On the sixth day she developed double vision and presented to the neurology department of a community hospital. Her headaches worsened, and lying down gave the only measure of limited relief. Subsequently she complained of headaches and after 24 hours she developed nausea and vomiting. During this manoeuvre the patient complained of a sudden sharp pain in her upper neck, and the procedure had to be stopped immediately. The chiropractioner grasped the head of the supine patient and exerted axial tension while rotating the head. A 40 year old woman undertook a spinal chiropractic manipulation.
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