Objective:

We present this case to encourage clinicians to consider tuberculous meningitis (TBM) as a potential diagnosis in patients with risk factors or history of tuberculosis (TB). This case demonstrates the importance of early suspicion and recognition of TBM to prevent devastating neurological complications and improve patient outcomes.

Background:

TB, caused by Mycobacterium tuberculosis, is mainly a disease of the lungs. In rare instances, it can extend to the central nervous system (CNS) resulting in TBM and cause severe  neurological deficits.

Design/Methods:

NA

Results:

We present the case of a 33-year-old male with history of latent TB and methamphetamine use, who presented with new-onset severe headache and myalgias for ten days. Examination revealed meningeal irritation signs. Despite the early initiation of empirical antimicrobial treatment for suspected CNS infection, his condition continued to deteriorate, leading to encephalopathy. Brain and vessels imaging studies revealed acute infarcts in multiple vascular territories and near-complete occlusion of the basilar artery, suggesting vasculitis. An extensive and atypical nodular and enhancing lesion found on cervical imaging, along with the previous finding and his history of latent TB, raised suspicion of TBM. Cerebrospinal fluid (CSF) analysis revealed low glucose (32 mg/dL), elevated protein (182 mg/dL), and lymphocytic pleocytosis (187 white blood cells), findings suggestive of fungal or tuberculous meningitis, but acid-fast bacillus smear and culture, and fungal culture yielded negative results. Digital subtraction angiography confirmed severe cerebral vasculitis, and despite the lack of a confirmatory test, the clinical suspicion of TBM remained high. He received antituberculosis treatment alongside high-dose steroids, resulting in resolution of his headache and encephalopathy.

Conclusions:

In patients with latent TB, even in the absence of positive confirmatory tests, considering the possibility of TBM when new neurological symptoms arise is crucial. Early diagnosis and prompt treatment are essential as untreated TBM can lead to severe and irreversible neurological deficits.