A 47-year-old man presented to the emergency department at the University of New Mexico with 4 days of diplopia and bilateral retro-orbital pain. He had been feeling well until 2 weeks earlier when he developed a flu-like illness with fever, chills, myalgias, nausea and vomiting. These symptoms resolved without treatment. Subsequently, the patient developed double vision and ocular pain. On review of symptoms, he also reported new unsteadiness with walking as well as right-sided facial and eyelid drooping.

The patient’s medical history was remarkable for two episodes of bilateral Bell’s palsy occurring more than 10 years earlier. He also reported hypertension and diabetes. The patient’s home medications included lisinopril. He denied any medication allergies. He was a current smoker and consumed approximately four alcoholic beverages per day.