ABSTRACT
A 68-year-old man presents with a 12-hour history of headache, confusion and declining consciousness. His wife says that he has recently completed oral chemotherapy for an ‘indolent form of leukaemia’. Examination reveals him to be responding to painful stimuli but not to verbal commands. He has bilateral axillary and inguinal lymphadenopathy. He is clinically jaundiced and anaemic. His spleen is palpably enlarged. He has neck stiffness, generalised hyper-reflexia and bilateral upgoing plantar reflexes. Fundal examination is normal, and there are no focal neurological signs. Full blood count shows
