(Don't) Blame it on Rio

A 43-year-old woman experienced blurred vision and pulsatile tinnitus after gaining 20 lbs. Six months later, optometric evaluation showed normal vision and bilateral optic nerve swelling. MRI brain with and without contrast was reportedly normal. One month later, she underwent a "Brazilian butt lift" surgery, with worsening headache and vision loss right eye. Neuro-ophthalmology consultation was requested to see if the surgical procedure was related to the vision loss. Examination showed visual acuity 20/500 RE and 20/25 LE, right RAPD, mild bilateral abduction deficits and severe papilledema. She was admitted for therapy with high dose acetazolamide and lumbar drain for presumed fulminant IIH. MRI brain and orbits showed leptomeningeal enhancement involving bilateral cerebellum, concerning for meningitis. CSF opening pressure was 25 cm water with normal WBC (1), low glucose (14) and high protein (58). CSF and blood testing were negative for infectious and auto-immune etiologies except for low titer MOG-IgG in blood (1:20). CSF cytopathology and flow cytometry were negative. Repeat lumbar puncture showed CSF WBC 47, low glucose (20) and elevated protein (115) with negative cytology and flow cytometry. MRI spine showed subtle enhancement of the cauda equina nerve roots. Extensive workup for underling malignancy was negative. She was discharged after 4 days with improved vision (20/60; 20/20) and optic disc appearance. She did well for 3 months before returning with worse vision in both eyes (20/100; 20/50) and recurrence of papilledema. MRI brain and orbits with and without contrast showed worsening leptomeningeal disease with bilateral multifocal, supra and infratentorial cortical and leptomeningeal enhancing lesions, with increased thickness and subtle bilateral prechiasmatic optic nerve enhancement. Lumbar puncture showed opening pressure 51cmH20, WBC 7, protein 124, glucose 14, with negative microbiology, cytopathology and flow studies. Acetazolamide was increased to 1500mg. A procedure was performed 6 weeks later.