Clinical Reasoning: A 16-year-old girl with ataxia, oscillopsia, and behavioral changes

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Abstract
A 16-year-old girl with no relevant medical history presented with 1 week of vertigo, tremulousness, and gait instability. She described the room as "moving and unsteady." She reported anxiety and had a panic attack in the emergency department. In the months prior to presentation, she displayed atypical irritability and aggressiveness toward her siblings. One week before the onset of vertigo, she completed a 5-day course of azithromycin for presumed sinusitis. She had not traveled in the prior year. The patient denied drug or alcohol use, sexual activity, sick contacts, or any recent tick or mosquito bites.