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MRI showed restricted diffusion in bilateral thalamic nuclei. Encephalitis and ischaemia were considered in the differential diagnosis. Cerebrospinal fluid IgM antibody for West Nile virus was positive. Sixteen days later, cranial nerve reflexes were lost. MRI showed restricted diffusion and increased T2 signal intensity in the dorsal medulla and increased T2 signal intensity without diffusion restriction in bilateral substantia nigra and dentate nuclei. 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