CASE PRESENTATION: A 25 year old woman with a past medical history of methamphetamine use and anorexia was admitted to an outside hospital (OSH) for a headache. She had been injecting methamphetamine into her left cheek. She quickly developed altered mental status. Blood cultures grew methicillin resistant staphylococcus aureus and imaging revealed septic emboli to her lungs and brain. She was transferred to our facility for higher level of care. On exam, she was afebrile and hemodynamically stable, but encephalopathic. She had spontaneous non-purposeful movement of all four limbs. She had an edematous face most notably bilateral eye edema with a fixed, dilated left pupil. She had an ulcerative lesion in her left check. Labs revealed urine positive for amphetamine. Review of the OSH computed tomography (CT) of her sinuses showed some evidence of left internal jugular vein (IJ) thrombosis. A CT angiogram then revealed acute thrombosis of the left IJ, left sigmoid and transverse sinuses, bilateral cavernous sinuses and bilateral superior ophthalmic veins. Subsequent MRI showed devastating neurologic injury with extensive bilateral acute cerebral infarctions. She continued to deteriorate with a worsening neurological examination, development of acute respiratory failure and development of shock despite treatment with antibiotics. At the family’s request, withdrawal of life sustaining treatment occurred on hospital day five.