The patient was treated with levetiracetam and hypertonic saline initially. Mental status deteriorated to Glasgow Coma Scale 5, leading to intubation. The left pupil was then noted to be fixed and dilated, concerning for brain herniation, prompting emergency neurosurgical decompressive hemicraniectomy, abscess drainage, and external ventricular drain placement. Two days later, the otology service performed right mastoidectomy, which revealed cholesteatoma in the epitympanum extending to the aditus ad antrum,  as well as mucopurulence in the middle ear and mastoid cavity. Brain abscess, CSF, and ear operative cultures grew Escherichia coli, Parvimonas micra (Peptostreptococcus micros), Peptoniphilus (Peptostreptococcus) asaccharolyticus, and Actinomyces europaeus. Intravenous antibiotics with Gram negative and anaerobic coverage were administered for 6 weeks.