A 50-year-old previously healthy Japanese woman who had a fever and headache for 24 days was admitted to our hospital. Initial examination confirmed a fever (39.4 C) and frontal tension-type headache. She had no history of travel overseas for several years or of pulmonary tuberculosis. Her consciousness was clear, with no neurologic deficits. Meningismus and papilledema were absent. Blood cell counts and the results of routine biochemical analysis were normal, expect for glucose (117 mg/dl). Human immunodeficiency virus was negative. Cranial computed tomography (CT) revealed a spotty calcification in the pons. Lumbar puncture on day 1 showed an initial pressure of 220 mmHg, 173 white cells/mm3 (98% lymphocytes), a protein concentration of 160 mg/dl, and a glucose concentration of 40 mg/dl. Intravenous acyclovir (10 mg/kg/day, 17 days) and glycerin (40 mg/day) were started for a suspected diagnosis of viral encephalitis. Cranial enhanced magnetic resonance imaging (MRI) on day 6 revealed no abnormal high-signal intensity or enhancement (Figure 1). On day 18, intravenous acyclovir was prescribed because a high fever with headache persisted, and the initial pressure and white cell count in CSF had increased to 335 mmHg and 380 white cells/mm3, respectively. The results of polymerase chain reaction amplification and Ziehl-Neelsen staining were positive for Mycobacterium tuberculosis in cerebrospinal fluid (CSF) on day 18. Isoniazid (300 mg/day), rifampicin (450 mg/day), pyrazinamide (1.5 g/day), and ethambutol (750 mg/day) were started concurrently with intravenous prednisolone (30 mg/day), the dose of which was tapered. During these antituberculosis treatments, the tension-type headache responded to diclofenac sodium or intravenous glycerin. However, the headache changed to posterior cervical pain accompanied by a high fever and meningismus on day 28. Repeated cranial enhanced MRI showed enhancement of the choroid plexus and posterior horn of the lateral ventricle, with no ventricular enlargement (Figure 1). On day 55, frontal headache developed in addition to the posterior cervical pain, often interrupting sleep and not responding to diclofenac sodium or intravenous glycerin. Meningismus persisted, and abducens paralysis was present. Repeated CSF examination showed that white cell count (200/mm3) had decreased in response to antituberculosis drugs, but the initial pressure (420 mmHg) and protein concentration (338 mg/dl) had increased, and the glucose concentration (30 mg/dl) had deceased. There was no evidence of hydrocephalus on a CT scan. Mannitol (120 mg/day) and dexamethasone (8 mg/day) with taper were started in addition to antituberculosis drugs and glycerin (20 mg/day). On day 66, headache with vomiting developed despite continued treatment. She writhed, turned her body, and moved her limbs violently on the bed, crying out "painful, painful." The patient was admitted in a confusional state, which could be coped with by her family. The score on the Glasgow Coma Scale (GCS) was 13. Cranial CT showed the same findings as previously, without hydrocephalus. On day 67, headache with vomiting and a confusional state, associated with removing clothes or extracting the intravenous line, further intensified, which constantly required surveillance by a physician or nurse. She was given several intravenous injections of pentazocine (7.5 mg) and diazepam (2.5 mg), with no response. The patient was sedated with propofol under mechanical ventilation because her respiratory function was suppressed by the previous injections. Intravenous propofol produced sedation for several hours, but even after increasing to the maximum dose of propofol (2.8 mg/kg/hr), the confusional state and high fever (  38 C) did not resolve. Papilledema was evident. On day 68, we switched from intravenous propofol to intravenous (2.0 ml/hr) combination therapy (total 40 ml) with butorphanol (20 mg) and midazolam (100 mg) in saline solution (10 ml). This butorphanol-midazolam combination therapy was given for 16 days (maximum dose, 3.0 ml/hr), and on day 1 of combination therapy the confusional state resolved. Subsequently, the patient was in a deeply sedated state while receiving mechanical ventilation, and the GCS score was 3. On day 69, the initial pressure (240 mmHg) and white cell count (195/mm3) had decreased. On day 73, she could nod in response to an easy question, and the body temperature rose only to 37.5 C. On day 78, intraspinal injections of isoniazid (100 mg per time) were started three times per week with taper and were continued for 5 months. On day 84, the butorphanol- midazolam combination therapy and mechanical ventilation were withdrawn, her consciousness was clear. The GCS score was 15, and she no longer complained of headache requiring medication. CSF analysis on day 87 showed further decreases in initial pressure (110 mmHg), white cell count (48/mm3), and protein level (117 mg/dl) and an increased glucose concentration (43 mg/dl). Seven months after admission, she was discharged from our hospital and subsequently received antituberculosis drugs for 14 months, resulting in complete recovery.