When the Lightning Strikes Twice: Navigating the Complex Terrain of Cerebral Tuberculosis

Abstract

Tuberculosis (TB), a Mycobacterium tuberculosis (Mtb) infection, remains a significant global health concern despite a declining incidence. This report highlights a complex case involving a 24-year-old patient from Angola who presented with a constellation of symptoms, including fever, weight loss, and neurological deficits. The patient had been on chronic corticosteroid therapy, a known risk factor for the reactivation of latent TB infection (LTBI). Her clinical course was marked by diagnostic challenges, such as a previous diagnosis of Kikuchi's disease and paradoxical progression despite appropriate tuberculostatic chemotherapy. Miliary TB, characterized by widespread dissemination of Mtb from the primary site of infection, can manifest in various extrapulmonary locations. Central nervous system (CNS) involvement, particularly TB meningitis, is the most severe form of TB, associated with significant morbidity and mortality. The diagnosis of miliary and CNS TB can be elusive due to nonspecific clinical presentations and imaging findings. This case underscores the importance of a high index of suspicion, especially in immunocompromised individuals, and the need for comprehensive microbiological analysis, including cerebrospinal fluid (CSF) examination, to confirm CNS involvement. Furthermore, this case illustrates the challenges associated with TB treatment, including the risk of drug toxicity, medication adherence, and the potential for drug resistance. Treatment duration for miliary TB is extended, typically lasting nine months to a year, and may require adaptation based on the patient's clinical response and drug penetration into the CNS. Corticosteroids play a critical role as adjuvant therapy, particularly in cases with perilesional edema or paradoxical reactions during treatment. This case underscores the complexity of diagnosing and managing miliary and CNS TB, emphasizing the importance of considering TB as a diagnostic possibility in patients with nonspecific symptoms and risk factors. Early identification, multidisciplinary collaboration, and tailored therapeutic strategies are essential for achieving optimal outcomes in such challenging cases. Additionally, screening for latent TB infection should be a priority for patients requiring immunosuppressive therapy to mitigate the risk of reactivation.

Keywords: antituberculosis therapy; central nervous system involvement; cerebral tuberculosis; corticosteroid therapy; disseminated tuberculosis; kikuchi's disease; latente tuberculosis reactivation.

Figure 1. Coronal body CT scan

Coronal body computed tomography (CT) scan showing pericardial effusion (red arrow) and hepatic stasis (blue arrow)

Figure 2. Supraclavicular lymph node histology

Low-power view showing necrotizing lymphadenitis change centered in the subcapsular region (inner blue area)

Figure 3. Amplified supraclavicular lymph node histology

High-power view showing the necrosis with eosinophils (inner blue area)

Figure 4. Chest CT scan

Chest CT showing a cavitation (red arrow) and adjacent consolidation (blue arrow) in the left upper lobe

Figure 5. Abdomen CT scan

Abdominal CT showing multiple hepatic lesions (red arrows) and splenic lesions (blue arrows) suggestive of TB involvement

Figure 6. Brain MRI lesions

Brain magnetic resonance imaging (MRI) showing occipital subcentimetric lesions with T2 hypodensity and ring enhancement (red arrow)

Figure 7. Brain MRI pituitary lesion

Brain MRI showing marked involvement of the pituitary gland after contrast