We present a 67 year old man admitted with progressive generalized weakness and altered mental status, found to have autoimmune encephalitis after his CSF tested positive for a rare onconeural antibody Zic4. Patients with Zic4 antibodies have been found to present with a cerebellar syndrome which correlated with his MRI brain findings of generalized atrophy, most prominent in the cerebellum, that were not present on previous scans. The malignancy survey was negative in his case. He failed multiple first line therapies including intravenous immunoglobulin (IVIG) and plasmapheresis with subsequent minimal neurocognitive response to intravenous steroids.  However, he responded to Rituximab with significant improvement in cognition but limited improvement in motor skills thus far. We also explore the possible association with recent epidural platelet rich plasma (PRP) therapy treatment.