Central nervous system vasculitis is an increasingly common, yet severe complication of tuberculous meningitis (TBM). Up to 20% of patients with widespread tuberculosis vasculitis present with stroke due to inflammation-induced occlusion of cerebral vessels. While rare, intraocular tuberculous infection can manifest as retinal vasculitis with associated retinal hemorrhages, retinal vein thromboses, and vision loss. This case highlights a unique intraocular manifestation of extensive TB vasculitis not previously reported in the literature.

A 21-year-old female Ghanian immigrant with no previous medical history presented with unresponsiveness and fever. Computer tomographic (CT) brain revealed hypoattenuation concerning for right territory MCA infarct. Magnetic resonance imaging (MRI) brain revealed extensive leptomeningeal enhancement consistent with basilar meningitis. Subsequent cerebrospinal fluid analysis, despite being negative for acid-fast bacilli, were highly suspicious of tuberculous meningitis in the setting of recent immigration, pleural effusions, and MRI findings. Patient was started on rifampin, isoniazid, pyrazinamide, ethambutol, and levofloxacin.

One month later, patient reported progressive and isolated right-sided vision loss that began prior to treatment. Repeat MRI only revealed new right frontal lobe edematous signal with no abnormalities noted in the orbits bilaterally. Magnetic resonance angiography (MRA) revealed underlying severe right MCA stenosis with a new left proximal ACA stenosis consistent with tuberculosis cerebral vasculitis. Ophthalmologic exam revealed a right afferent pupillary defect yet an intact retina. She was started on high-dose dexamethasone with significant improvement in vision, consistent with an inflammatory etiology of vision loss. Patient has since completed anti-tuberculosis therapy and steroid regimen without recurrence in symptoms.

This case showcases a new presentation of intraocular tuberculosis involving isolated vision loss in the setting of intracranial vasculitis without associated orbital or retinal findings.