A two-month-old Standardbred filly presented for an acute onset of head tremors. Medical history included administration of Rhodococcus equi hyperimmune plasma and a mandibular fracture. Physical exam revealed tachypnea, tachycardia, fever, and adventitious lung sounds. On neurologic examination the foal displayed titubation, cerebellar ataxia, and an exaggerated menace response, which were localized to a cerebellar lesion. Analysis of blood and cerebrospinal fluid, thoracic imaging, and cultures of blood and endotracheal tube exudate supported a presumptive diagnosis of Rhodococcus equi septicemia with cerebellar and pulmonary involvement. The foal was hospitalized and responded well to treatment with azithromycin, rifampin, gastroprotectants, flunixin meglumine, thiamine, clopidogrel, mannitol, and vitamin E. This report will discuss farm prevention, screening, and treatment of foals for R. equi and its extrapulmonary manifestations.