not-yet-known not-yet-known not-yet-known unknown CASE HISTORY: Second Presentation The patient presented to us again 36 hours later (day 9) with a chief complaint of headache and facial weakness. He was unable to recall when this occurred after leaving the ED. His exam was now notable for a right-sided facial paralysis with involvement of the forehead. He was unable to fully close his right eye, which was consistent with Bell’s palsy. He had no other neurological deficits and could ambulate normally. He had no meningeal signs, but his severe headache in the setting of neurological deficits gave concern for meningitis. His skin lesion had progressed to an area of erythema with a necrotic center (Figure 1).