A 27-year-old Zambian man presented to the neurology clinic with a 1-month history of mental status changes and a 5-day history of visual and auditory hallucinations, paranoia, and difficulty walking. Notably, a month before presentation, he became increasingly withdrawn and was diagnosed with depression in a psychiatry clinic. His medical history was also significant for an anal fissure with hematochezia and severe anemia (hemoglobin 4 g/dL) 6 months prior. Examination revealed a thin patient responding to auditory and verbal hallucinations who accused the examiner of trying to harm him. He had a spastic tetraparesis with 2/5 power in all limbs, hyperreflexia with clonus, and a palpable bladder and was unable to walk. Sensory examination was unreliable because of the patient’s mental state.