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Central nervous system (CNS) tuberculosis is a postprimary form of tuberculosis with high mortality and morbidity rates, even with early diagnosis and treatment. Focal tuberculous cerebritis is extremely rare, typically occurring in patients without AIDS, and often associated with tuberculous meningitis. In endemic regions, it should be a primary consideration when encountering cerebral anomalies suggestive of granulomatous conditions. Its meningeal pseudo-tumor form poses a significant diagnostic challenge.We present the case of a 26-year-old man who arrived at the emergency room with cerebellar and pyramidal syndrome. Cerebral magnetic resonance imaging (MRI) revealed an expansive lesion in the right hemicerebellum with glove-finger edema and leptomeningeal thickening. Given the MRI findings and associated lung involvement, the diagnosis of tuberculosis was strongly suggested in our epidemiological context. Due to contraindications for lumbar puncture, high surgical risk, and strong clinical and radiological suspicion, antituberculous treatment was initiated in collaboration with neurologists and infectious disease specialists.The clinical and radiologic manifestations of CNS tuberculosis can mimic other infectious and noninfectious neurological conditions, as seen in our patient. Thus, familiarity with the imaging presentations of CNS tuberculosis among infectious disease specialists and radiologists is crucial for prompt and accurate diagnosis.

Background: Cerebrospinal fluid (CSF) Xpert MTB/RIF assay is an initial test for the diagnosis of tuberculous meningitis (TBM). Nevertheless, it is not very clear which of the factors govern CSF-Gene Xpert/MTB positivity. Objective: Hence, we aimed to assess the relationship, if any, between the clinical, laboratory and radiological parameters of the central nervous system (CNS) tuberculosis patients and the Gene Xpert study in CSF in such patients. Methods and Material: First, we studied 200 patients with CNS tuberculosis according to the case definition, and subsequently, we performed a Gene Xpert study on the CSF of these patients. Then, we correlated the clinical, radiological, and CSF criteria with the Gene Xpert positivity using the univariate binary logistic regression method via SPSS 20 (P-value <0.05). Results: Seventy-five (37.5%) patients (57.3% females) of median 24 years of age, were CSF-Gene Xpert/MTB-positive and 125 (62.5%) patients were negative. The mean duration of illness (P = 0.017), weight loss or failure to thrive (P < 0.001), loss of consciousness or seizure (P = 0.001), signs of meningeal irritation (P = 0.027), stage III of TBM (P < 0.001), evidence of dissemination (P = 0.003), basal exudates (P = 0.004), hydrocephalus (P = 0.018), CSF lymphocytic predominance (P < 0.001), and reduced CSF glucose (P = 0.011) correlated significantly with positive the Gene Xpert/MTB results. Also, Gene Xpert had a sensitivity of 80% and a specificity of 74.84% against culture Xpert. Conclusions Xpert MTB/RIF might be more useful in the later stages of the disease and those with more severe disease. [ABSTRACT FROM AUTHOR]

Background Few treatment options exist for patients with severe central nervous system (CNS) tuberculosis (TB) worsening due to inflammatory lesions, despite optimal antitubercular therapy (ATT) and steroids. Data regarding the efficacy and safety of infliximab in these patients are sparse. Methods We performed a matched retrospective cohort study based on Medical Research Council (MRC) grading system and modified Rankin Scale (mRS) scores comparing 2 groups of adults with CNS TB. Cohort A received at least 1 dose of infliximab after optimal ATT and steroids between March 2019 and July 2022. Cohort B received only ATT and steroids. Disability-free survival (mRS score ≤2) at 6 months was the primary outcome. Results Baseline MRC grades and mRS scores were similar between the cohorts. Median duration before initiation of infliximab therapy from start of ATT and steroids was 6 (IQR: 3.7–13) months and for neurological deficits was 4 (IQR: 2–6.2) months. Indications for infliximab were symptomatic tuberculomas (20/30; 66.7%), spinal cord involvement with paraparesis (8/30; 26.7%), and optochiasmatic arachnoiditis (3/30; 10%), worsening despite adequate ATT and steroids. Severe disability (5/30 [16.7%] and 21/60 [35%]) and all-cause mortality (2/30 [6.7%] and 13/60 [21.7%]) at 6 months were lower in cohort A versus cohort B, respectively. In the combined study population, only exposure to infliximab was positively associated (aRR: 6.2; 95% CI: 2.18–17.83; P =.001) with disability-free survival at 6 months. There were no clear infliximab-related side effects noted. Conclusions Infliximab may be an effective and safe adjunctive strategy among severely disabled patients with CNS TB not improving despite optimal ATT and steroids. Adequately powered phase 3 clinical trials are required to confirm these early findings. [ABSTRACT FROM AUTHOR]

Abstract Background Tuberculous meningitis, a rare but severe form of extrapulmonary tuberculosis, frequently affects cranial nerves. While nerves III, VI and VII are commonly involved, involvement of caudal cranial nerves is rarely described. Here, we report a rare case of bilateral vocal cord palsy secondary to caudal cranial nerve involvement in tuberculous meningoencephalitis, that occurred in Germany, a country with low tuberculosis incidence. Case presentation A 71-year-old woman was transferred for further treatment of hydrocephalus as a complication of presumed bacterial meningitis with unknown pathogen at that time. Because of decreased consciousness, intubation was performed and an empiric antibiotic therapy with ampicillin, ceftriaxone and acyclovir was initiated. Upon admission to our hospital, an external ventricular drainage was placed. Cerebrospinal fluid analysis revealed Mycobacterium tuberculosis as the causative pathogen, and antitubercular treatment was initiated. Extubation was possible one week after admission. Eleven days later, the patient developed inspiratory stridor that worsened within a few hours. Flexible endoscopic evaluation of swallowing (FEES) revealed new-onset bilateral vocal cord palsy as the cause of respiratory distress, which required re-intubation and tracheostomy. The bilateral vocal cord palsy persisted despite continued antitubercular therapy on the follow-up examination. Conclusion Considering the aetiology of infectious meningitis, cranial nerve palsies may be suggestive for tuberculous meningitis as underlying disease given their rarity in other bacterial forms of meningitis. Nevertheless, intracranial involvement of inferior cranial nerves is rare even in this specific entity, as only extracranial lesions of inferior cranial nerves have been reported in tuberculosis. With this report of a rare case of bilateral vocal cord palsy due to intracranial involvement of the vagal nerves, we emphasize the importance of timely initiation of treatment for tuberculous meningitis. This may help to prevent serious complications and associated poor outcome since the response to anti-tuberculosis therapy may be limited.

Tuberculous meningitis (TBM) is a potentially life-threatening form of tuberculosis (TB) that affects the central nervous system. Its management in patients with concomitant chronic liver disease (CLD) presents unique challenges due to altered drug metabolism with potentially impaired spinal fluid drug penetration and hepatotoxicity. The standard regimen for TBM includes isoniazid (INH) and rifampin (RIF), and Pyrazinamide (PZA) which are metabolized by the liver and may cause hepatotoxicity, which can exacerbate preexisting liver disease. Thus, careful consideration is required to balance therapeutic efficacy with potential drug-induced hepatotoxicity. Regular monitoring of liver function tests and clinical response is essential to minimize adverse effects and optimize treatment outcomes. Further research is needed to establish evidence-based guidelines for the tailored management of TBM in this vulnerable patient subset. Overall, the treatment of TBM in patients with severe liver disease should be individualized and closely monitored.

Introduction: Central nervous system (CNS) tuberculosis (TB) is the most severe form of TB due to its high mortality and functional sequelae. There are several differential diagnoses for TB; and, it can also cause secondary conditions, such as vasculitis. Methodology: 155 biopsies, corresponding to 155 different patients out of 5,386 registered biopsies from 2008-2013, met the criteria of unknown etiology vasculitis and evidence of cerebral vascular disease. These were analyzed to assess the presence of central nervous system TB. The selected cases were assessed with Suzaan Marais (SM) criteria for clinical tuberculosis. After that, Ziehl-Neelsen (ZN) staining and polymerase chain reaction (PCR) were performed to amplify a fragment of the insertion sequence IS6110 of M. tuberculosis. 21 patients met the criteria for definitive tuberculosis by ZN staining and PCR, and 2 met the criteria for possible tuberculosis. Tumor necrosis factor (TNF)- α, TNF-R1, and TNF-R2 were determined by immunohistochemistry in histological sections from formalin-fixed paraffin-embedded (FF-PE) tissues in the 23 selected patients. Results: Granulomatous TB was present in almost half of the cases. TNF-R1 and TNF-R2 were expressed mainly in blood vessels, histiocytes, and macrophages. TNF-R2 expression was higher than the other markers, which suggests an anti-inflammatory response against M. tuberculosis Conclusions: The histopathological presentation of TB is not always limited to granulomas, abscesses, or meningitis; there are also clinical presentations characterized only with chronic inflammation of nervous and vascular tissue. [ABSTRACT FROM AUTHOR]

Tuberculosis is a contagious disease that has been a concern for humanity throughout history, being recognized and referred to as the white plague. Since ancient times, starting with Hippocrates and Galen of Pergamon, doctors and scientists have attempted to understand the pathogenesis of tuberculosis and its manifestations in the brain. If, in the medieval period, it was believed that only the touch of a king could cure the disease, it was only in the early 17th and 18th centuries that the first descriptions of tuberculous meningitis and the first clinico-pathological correlations began to emerge. While the understanding of neurotuberculosis progressed slowly, it was only after the discovery of the pathogenic agent in the late 19th century that there was an upward curve in the occurrence of treatment methods. This review aims to embark on an odyssey through the centuries, from ancient Egypt to the modern era, and explore the key moments that have contributed to the emergence of a new era of hope in the history of neurotuberculosis. Understanding the history of treatment methods against this disease, from empirical and primitive ones to the emergence of new drugs used in multi-drug-resistant tuberculosis, leads us, once again, to realize the significant contribution of science and medicine in treating a disease that was considered incurable not long ago. [ABSTRACT FROM AUTHOR]

Background: Tuberculous meningitis, a rare but severe form of extrapulmonary tuberculosis, frequently affects cranial nerves. While nerves III, VI and VII are commonly involved, involvement of caudal cranial nerves is rarely described. Here, we report a rare case of bilateral vocal cord palsy secondary to caudal cranial nerve involvement in tuberculous meningoencephalitis, that occurred in Germany, a country with low tuberculosis incidence. Case presentation: A 71-year-old woman was transferred for further treatment of hydrocephalus as a complication of presumed bacterial meningitis with unknown pathogen at that time. Because of decreased consciousness, intubation was performed and an empiric antibiotic therapy with ampicillin, ceftriaxone and acyclovir was initiated. Upon admission to our hospital, an external ventricular drainage was placed. Cerebrospinal fluid analysis revealed Mycobacterium tuberculosis as the causative pathogen, and antitubercular treatment was initiated. Extubation was possible one week after admission. Eleven days later, the patient developed inspiratory stridor that worsened within a few hours. Flexible endoscopic evaluation of swallowing (FEES) revealed new-onset bilateral vocal cord palsy as the cause of respiratory distress, which required re-intubation and tracheostomy. The bilateral vocal cord palsy persisted despite continued antitubercular therapy on the follow-up examination. Conclusion: Considering the aetiology of infectious meningitis, cranial nerve palsies may be suggestive for tuberculous meningitis as underlying disease given their rarity in other bacterial forms of meningitis. Nevertheless, intracranial involvement of inferior cranial nerves is rare even in this specific entity, as only extracranial lesions of inferior cranial nerves have been reported in tuberculosis. With this report of a rare case of bilateral vocal cord palsy due to intracranial involvement of the vagal nerves, we emphasize the importance of timely initiation of treatment for tuberculous meningitis. This may help to prevent serious complications and associated poor outcome since the response to anti-tuberculosis therapy may be limited. [ABSTRACT FROM AUTHOR]

Central nervous system tuberculosis (CNS‐TB) is one of the most devastating and life‐threatening conditions having high mortality and morbidity. Here, we report a 12‐year‐old child with pulmonary tuberculosis and pleural effusion presenting with ischemic stroke as an important manifestation of central nervous system tuberculosis. Rapid and accurate diagnoses with timely treatment are the best ways to improve the survival rate of CNS‐TB. This report focuses the need to consider CNS‐TB in the differential diagnosis of children with stoke living in areas of high tuberculosis. [ABSTRACT FROM AUTHOR]

Abstract Central nervous system tuberculosis (CNS‐TB) is one of the most devastating and life‐threatening conditions having high mortality and morbidity. Here, we report a 12‐year‐old child with pulmonary tuberculosis and pleural effusion presenting with ischemic stroke as an important manifestation of central nervous system tuberculosis.

Tuberculosis is a contagious disease that has been a concern for humanity throughout history, being recognized and referred to as the white plague. Since ancient times, starting with Hippocrates and Galen of Pergamon, doctors and scientists have attempted to understand the pathogenesis of tuberculosis and its manifestations in the brain. If, in the medieval period, it was believed that only the touch of a king could cure the disease, it was only in the early 17th and 18th centuries that the first descriptions of tuberculous meningitis and the first clinico-pathological correlations began to emerge. While the understanding of neurotuberculosis progressed slowly, it was only after the discovery of the pathogenic agent in the late 19th century that there was an upward curve in the occurrence of treatment methods. This review aims to embark on an odyssey through the centuries, from ancient Egypt to the modern era, and explore the key moments that have contributed to the emergence of a new era of hope in the history of neurotuberculosis. Understanding the history of treatment methods against this disease, from empirical and primitive ones to the emergence of new drugs used in multi-drug-resistant tuberculosis, leads us, once again, to realize the significant contribution of science and medicine in treating a disease that was considered incurable not long ago.

Background: Children with tuberculous meningitis (TBM) present with diagnostic challenges as they often have atypical clinical features., Objective: To describe the baseline characteristic features of children diagnosed with central nervous system (CNS) TB (TBM and tuberculoma)., Design: Retrospective descriptive study., Methods: Children less than 12 years presenting with neurological signs and symptoms were assessed for a therapeutic TBM trial eligibility. The results of their clinical, laboratory, neuroimaging, cerebrospinal fluid evaluations were analysed for TBM diagnosis., Results: Of 600 children evaluated, 61(10%) had CNS tuberculosis; TBM 47, tuberculoma 14. 20(33%) had definite TBM. Mean age of children with TBM was 5 ± 3.4 years. Of 47, 13(28%), 21(45%) and 13(28%) had grade I, II, and III disease respectively. Abnormalities suggestive of TBM in MRI and computed tomography brain were observed in 76% (26/34) and 77% (24/31) respectively. Abnormal cerebrospinal fluid white blood cell count, protein and glucose were observed in 56% (24/43), 49% (22/45), 47% (21/45) respectively. Among 41 patients with TBM followed up until discharge, five died., Conclusion: Younger children with TBM have severe forms. Confirmatory results may not be available in all. A holistic approach to care including addressing complications of hydrocephalus and strokes is needed., (© The Author(s), 2024.)

Tuberculous meningitis (TBM) is a potentially life-threatening form of tuberculosis (TB) that affects the central nervous system. Its management in patients with concomitant chronic liver disease (CLD) presents unique challenges due to altered drug metabolism with potentially impaired spinal fluid drug penetration and hepatotoxicity. The standard regimen for TBM includes isoniazid (INH) and rifampin (RIF), and Pyrazinamide (PZA) which are metabolized by the liver and may cause hepatotoxicity, which can exacerbate preexisting liver disease. Thus, careful consideration is required to balance therapeutic efficacy with potential drug-induced hepatotoxicity. Regular monitoring of liver function tests and clinical response is essential to minimize adverse effects and optimize treatment outcomes. Further research is needed to establish evidence-based guidelines for the tailored management of TBM in this vulnerable patient subset. Overall, the treatment of TBM in patients with severe liver disease should be individualized and closely monitored., Competing Interests: The authors declare that they have no competing interests. This manuscript has not been published and is not under consideration for publication elsewhere. Additionally, all authors have approved this paper’s contents and agreed to the journal´s submission policies., (© 2024 The Authors.)

Central nervous system (CNS) tuberculosis is a postprimary form of tuberculosis with high mortality and morbidity rates, even with early diagnosis and treatment. Focal tuberculous cerebritis is extremely rare, typically occurring in patients without AIDS, and often associated with tuberculous meningitis. In endemic regions, it should be a primary consideration when encountering cerebral anomalies suggestive of granulomatous conditions. Its meningeal pseudo-tumor form poses a significant diagnostic challenge. We present the case of a 26-year-old man who arrived at the emergency room with cerebellar and pyramidal syndrome. Cerebral magnetic resonance imaging (MRI) revealed an expansive lesion in the right hemicerebellum with glove-finger edema and leptomeningeal thickening. Given the MRI findings and associated lung involvement, the diagnosis of tuberculosis was strongly suggested in our epidemiological context. Due to contraindications for lumbar puncture, high surgical risk, and strong clinical and radiological suspicion, antituberculous treatment was initiated in collaboration with neurologists and infectious disease specialists. The clinical and radiologic manifestations of CNS tuberculosis can mimic other infectious and noninfectious neurological conditions, as seen in our patient. Thus, familiarity with the imaging presentations of CNS tuberculosis among infectious disease specialists and radiologists is crucial for prompt and accurate diagnosis., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

A five-month-old infant presented with fever and cough for 3 weeks. She was diagnosed with multiple tuberculomas and cavitating pulmonary tuberculosis. She was a household contact of an open case of tuberculosis (TB) and developed severe disease, although she had received the Bacillus Calmette–Guérin (BCG) vaccine and had no primary or secondary immunodeficiency. In infants, due to low levels of cell mediated immunity, tuberculosis can be severe and dissemination of tuberculosis to the central nervous system (CNS) can occur very early without following the usual time frame. CNS TB may not have symptoms in the early stages in infants and may require neuroimaging for diagnosis. This is the youngest child that has been reported with multiple CNS tuberculomas.

Introduction: Central Nervous System tuberculosis (CNS-TB) is the most lethal form of extra-pulmonary TB, especially in children. In this study, we have discussed patterns of drug resistance in pediatric CNS-TB.Materials and Methods: Prospective observational study conducted on 100 children at a tertiary care center. Diagnosed cases of CNS-TB were enrolled. GeneXpert MTB/RIF was used upfront for diagnosis, and in cases where TB MGIT culture was positive, a phenotypic Drug Susceptibility Test (DST) was done. Patients were divided into resistant to at least one drug (DR) and drug-susceptible (DS). Various parameters were compared between these groups.Results: Mean age of participants was 5.84 ± 3.5 years, with a male-to-female ratio of 1.08 : 1; 14% of children had drug-resistant CNS TB (DR-CNS-TB). A higher proportion of children previously treated for TB were associated with drug resistance (p = 0.009), and those with disseminated TB also had a higher drug resistance (p = 0.002). Apart from this, the DR and DS groups had no statistically significant differences in demographic, clinical or epidemiological parameters.Conclusions: Previous history of being treated for TB and disseminated TB was an independent risk factor for DR-CNS-TB. Ensuring proper adherence and compliance to anti-tubercular treatment could help in preventing the emergence of DR TB. [ABSTRACT FROM AUTHOR]

Abstract Background Central and peripheral nervous system symptoms and complications are being increasingly recognized among individuals with pandemic SARS-CoV-2 infections, but actual detection of the virus or its RNA in the central nervous system has rarely been sought or demonstrated. Severe or fatal illnesses are attributed to SARS-CoV-2, generally without attempting to evaluate for alternative causes or co-pathogens. Case presentation A five-year-old girl with fever and headache was diagnosed with acute SARS-CoV-2-associated meningoencephalitis based on the detection of its RNA on a nasopharyngeal swab, cerebrospinal fluid analysis, and magnetic resonance imaging findings. Serial serologic tests for SARS-CoV-2 IgG and IgA showed seroconversion, consistent with an acute infection. Mental status and brain imaging findings gradually worsened despite antiviral therapy and intravenous dexamethasone. Decompressive suboccipital craniectomy for brain herniation with cerebellar biopsy on day 30 of illness, shortly before death, revealed SARS-CoV-2 RNA in cerebellar tissue using the Centers for Disease Control and Prevention 2019-nCoV Real-Time Reverse Transcriptase-PCR Diagnostic Panel. On histopathology, necrotizing granulomas with numerous acid-fast bacilli were visualized, and Mycobacterium tuberculosis complex DNA was detected by PCR. Ventricular cerebrospinal fluid that day was negative for mycobacterial DNA. Tracheal aspirate samples for mycobacterial DNA and culture from days 22 and 27 of illness were negative by PCR but grew Mycobacterium tuberculosis after 8 weeks, long after the child’s passing. She had no known exposures to tuberculosis and no chest radiographic findings to suggest it. All 6 family members had normal chest radiographs and negative interferon-γ release assay results. The source of her tuberculous infection was not identified, and further investigations by the local health department were not possible because of the State of Michigan-mandated lockdown for control of SARS-CoV-2 spread. Conclusion The detection of SARS-CoV-2 RNA in cerebellar tissue and the demonstration of seroconversion in IgG and IgA assays was consistent with acute SARS-CoV-2 infection of the central nervous infection. However, the cause of death was brain herniation from her rapidly progressive central nervous system tuberculosis. SARS-CoV-2 may mask or worsen occult tuberculous infection with severe or fatal consequences.

Background and objective Tuberculosis (TB), caused by Mycobacterium tuberculosis, remains a significant global health concern, with India being a hotspot for the disease burden. Central nervous system (CNS) tuberculosis, though comprising a smaller proportion of total TB cases, is associated with significant morbidity and mortality. This study aimed to explore the utility of diffusion tensor imaging (DTI) in assessing the microstructural changes in white matter tracts associated with CNS tuberculosis. Materials and methods This study was conducted over two years at the All India Institute of Medical Sciences, Rishikesh. We employed a cross-sectional observational design and included patients with definite or highly probable tuberculous meningitis, alongside healthy controls. Results Our findings revealed a significant reduction in fractional anisotropy (FA) values in various white matter tracts of patients with CNS tuberculosis compared to healthy individuals. This reduction in FA correlated with the severity of tuberculous meningitis, particularly in the corpus callosum. Additionally, DTI highlighted distinct patterns of white matter involvement around intraparenchymal lesions, suggesting potential implications for clinical outcomes. The study emphasizes the utility of FA values in grading disease severity and prognosticating treatment outcomes in CNS tuberculosis. Conclusions Overall, this study provides valuable insights into the microstructural alterations in white matter tracts associated with CNS tuberculosis, highlighting the potential of DTI in early diagnosis, grading disease severity, and monitoring treatment response. We believe these findings will pave the way for further research to optimize the clinical management of this debilitating disease., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Institutional Ethics Committee, All India Institute of Medical Sciences, Rishikesh issued approval AIIMS/IEC/19/706. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Saurya et al.)

Tuberculosis of the central nervous system (CNS-TB) is a critical disease with poor prognosis if not diagnosed and treated early. A regimen of drugs with good CNS penetration is required for treatment. Treatment options are limited in case of hypersensitivity reaction of the recommended regimen. We are reporting a rare instance where a patient developed hypersensitivity to both first line agents (isoniazid and rifampin) for CNS-TB and was successfully desensitized against both these medications to complete the treatment course using the rapid desensitization process. There have been reported cases of desensitization to anti tuberculous medications in cases with pulmonary tuberculosis and hypersensitivity reaction. In this review article we discuss the prior used methods of slow and rapid desensitization in case on non-CNS tuberculosis infections. This is the first reported case to use similar method of rapid desensitization in treatment of central nervous system infection.

A five-month-old infant presented with fever and cough for 3 weeks. She was diagnosed with multiple tuberculomas and cavitating pulmonary tuberculosis. She was a household contact of an open case of tuberculosis (TB) and developed severe disease, although she had received the Bacillus Calmette–Guérin (BCG) vaccine and had no primary or secondary immunodeficiency. In infants, due to low levels of cell mediated immunity, tuberculosis can be severe and dissemination of tuberculosis to the central nervous system (CNS) can occur very early without following the usual time frame. CNS TB may not have symptoms in the early stages in infants and may require neuroimaging for diagnosis. This is the youngest child that has been reported with multiple CNS tuberculomas. [ABSTRACT FROM AUTHOR]

Tuberculosis is emerging worldwide across diverse populations and geographies; unrestricted by the social divide and the geographical barriers in today's interconnected world. This rise in its prevalence can be linked to multiple factors including urbanisation, spurt in global travel, population explosion, migration and HIV infection. The varied and complex clinical presentation of intracranial tuberculosis tricks even the best of the clinicians. This along with the other facets associated with its management including drug resistance, paradoxical reaction, underlying HIV infection can make it particularly challenging. Imaging has a definitive role in the evaluation and follow-up of intracranial tuberculosis and MRI is the cornerstone in this regard. Typical features of intracranial tuberculosis are well-described. However, it is not infrequent to encounter atypical and bizarre presentations, both clinically and on imaging. A holistic clinical and imaging review of difficult cases, including newer MRI techniques, is necessary for the neuroradiologist, neurologist and the neurosurgeon to arrive at the right diagnosis in a timely fashion. • Intracranial tuberculosis is emerging across the globe. • Imaging studies, particularly MRI is the cornerstone in the diagnosis. • Typical and atypical features contribute to a diverse imaging pattern. • Knowledge of the various possibilities and advanced MRI techniques is essential. [ABSTRACT FROM AUTHOR]

Tuberculoma involving the cerebellopontine angle is very rare. Preoperative neuroradiological features of such lesions may mimic neoplastic lesions. Our case presented with cerebellar features and multiple cranial nerve palsy. Neuroimaging mimicked CP angle neoplastic lesion. Antitubercular therapy and steroids resulted in significant clinical improvement and marked radiological reduction in size of the lesion. In our subcontinent a treatable infective cause like tuberculosis should be ruled out in CP angle lesions. Although rare but definitely a possibility to be considered.

Background: Central and peripheral nervous system symptoms and complications are being increasingly recognized among individuals with pandemic SARS-CoV-2 infections, but actual detection of the virus or its RNA in the central nervous system has rarely been sought or demonstrated. Severe or fatal illnesses are attributed to SARS-CoV-2, generally without attempting to evaluate for alternative causes or co-pathogens.Case Presentation: A five-year-old girl with fever and headache was diagnosed with acute SARS-CoV-2-associated meningoencephalitis based on the detection of its RNA on a nasopharyngeal swab, cerebrospinal fluid analysis, and magnetic resonance imaging findings. Serial serologic tests for SARS-CoV-2 IgG and IgA showed seroconversion, consistent with an acute infection. Mental status and brain imaging findings gradually worsened despite antiviral therapy and intravenous dexamethasone. Decompressive suboccipital craniectomy for brain herniation with cerebellar biopsy on day 30 of illness, shortly before death, revealed SARS-CoV-2 RNA in cerebellar tissue using the Centers for Disease Control and Prevention 2019-nCoV Real-Time Reverse Transcriptase-PCR Diagnostic Panel. On histopathology, necrotizing granulomas with numerous acid-fast bacilli were visualized, and Mycobacterium tuberculosis complex DNA was detected by PCR. Ventricular cerebrospinal fluid that day was negative for mycobacterial DNA. Tracheal aspirate samples for mycobacterial DNA and culture from days 22 and 27 of illness were negative by PCR but grew Mycobacterium tuberculosis after 8 weeks, long after the child's passing. She had no known exposures to tuberculosis and no chest radiographic findings to suggest it. All 6 family members had normal chest radiographs and negative interferon-γ release assay results. The source of her tuberculous infection was not identified, and further investigations by the local health department were not possible because of the State of Michigan-mandated lockdown for control of SARS-CoV-2 spread.Conclusion: The detection of SARS-CoV-2 RNA in cerebellar tissue and the demonstration of seroconversion in IgG and IgA assays was consistent with acute SARS-CoV-2 infection of the central nervous infection. However, the cause of death was brain herniation from her rapidly progressive central nervous system tuberculosis. SARS-CoV-2 may mask or worsen occult tuberculous infection with severe or fatal consequences. [ABSTRACT FROM AUTHOR]

Growth hormone is among the most common hormones to be deficient in pituitary insult. It can occur either in isolation or combined with other hormone deficiencies. Growth hormone deficiency in adults (AGHD) can be due to causes acquired in adulthood or have a childhood-onset etiology, but the former is about three times more common. Usual causes of AGHD include mass effects due to a pituitary tumour, and/or its treatment (surgery, medical therapy, or radiotherapy), or radiotherapy to the head and neck region for non-pituitary lesions. The unusual or lesser-known causes of AGHD, are usually due to non-tumoral etiology and range from vascular and infective to inflammatory and miscellaneous causes. These not only expand the spectrum of AGHD but may also contribute to increased morbidity, adverse metabolic consequences, and mortality due to the primary condition, if unrecognised. The review features these lesser-known and rare causes of AGHD and highlights their clinical and diagnostic implications. [ABSTRACT FROM AUTHOR]

Introduction: The underlying diagnosis of cavernous sinus disease is difficult to confirm in HIV-coinfected patients owing to the lack of histological confirmation. In this retrospective case series, we highlight the challenges in confirming the diagnosis and managing these patients. Results: The clinical, laboratory and radiological data of 23 HIV-infected patients with cavernous sinus disease were analysed. The mean age of patients was 38 years. The mean CD4+ count was 390 cells/μL. Clinically, patients presented with unilateral disease (65%), headache (48%), diplopia (30%) and blurred vision (30%). Third (65%) and sixth (57%) nerve palsies in isolation and combination (39%) were most common. Isolated fourth nerve palsy did not occur. Tuberculosis (17%) was the most commonly identified disorder followed by high-grade B-cell lymphoma (13%), meningioma (13%), metastatic carcinoma (13%) and neurosyphilis (7%). In 22% of the patients, there was no confirmatory evidence for a diagnosis. The patients were either treated empirically for tuberculosis or improved spontaneously when antiretroviral therapy was started. Cerebrospinal fluid was helpful in 4/13 (31%) of patients where it was not contraindicated. Only 3/23 (13%) of the patients had a biopsy of the cavernous sinus mass. The outcomes varied, and follow-up was lacking in the majority of patients. Conclusion: In HIV-infected patients, histological confirmation of cavernous sinus pathology is not readily available for various reasons. In resource-limited settings, one should first actively search for extracranial evidence of tuberculosis, lymphoma, syphilis and primary malignancy and manage appropriately. Only if such evidence is lacking should a referral for biopsy be considered.

Neurotuberculosis remains a mystery and presents a formidable challenge in diagnosis and management. While pulmonary tuberculosis has a well understood pathophysiology and well researched management strategies, CNS tuberculosis still has plenty of unanswered questions. The purpose of this review is to highlight the debatable issues in the current understanding of the clinical, diagnostic, and therapeutic aspects of Neurotuberculosis., (Copyright © 2023 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.)

Aim: This questionnaire-based national survey is aimed at understanding the patterns of practice of various aspects of central nervous system (CNS) tuberculosis (TB) among neurologists.Settings and Design: Neurology department of a tertiary medical college.Materials and Methods: A questionnaire was sent through email to all practicing neurologists in India. The responses were analyzed.Statistical Analysis: Inferential statistics.Results: In all, 144 responses were received (out of the 853 questionnaires sent). The major discrepancies were in the primary antitubercular drug regimen (HRZE + HR), duration for tubercular meningitis (TBM) [12 months] and tuberculoma (12-18 months) to develop, follow-up (varied), linezolid use (varied), proportion of drug-resistant cases (<25%), and not taking histological aids (91%). The cerebrospinal fluid (CSF) TB polymerase chain reaction (PCR) utility (75%), not using CSF adenosine deaminase [ADA] (58%), the strategy to stop antitubercular drugs, and the use of steroids (77%) were according to guidelines.Conclusion: The present survey, for the first time, provides ground-level evidence of various aspects of CNS TB as practiced by neurologists in India. The major diversity was observed in therapeutics such as the choice of antitubercular drugs, its duration, linezolid use beyond the recommended duration, and knowledge of drug resistance. The monitoring aspects of CNS TB also showed variations. The investigational aspects of CNS TB such as using TB PCR, not using CSF ADA, and regular neuroimaging revealed a good clinical practice. Other CSF parameters require uniformity. This survey thus helps to identify areas of future work in CNS TB in India. [ABSTRACT FROM AUTHOR]

Tuberculosis of the central nervous system (CNS-TB) is a critical disease with poor prognosis if not diagnosed and treated early. A regimen of drugs with good CNS penetration is required for treatment. Treatment options are limited in case of hypersensitivity reaction of the recommended regimen. We are reporting a rare instance where a patient developed hypersensitivity to both first line agents (isoniazid and rifampin) for CNS-TB and was successfully desensitized against both these medications to complete the treatment course using the rapid desensitization process. There have been reported cases of desensitization to anti tuberculous medications in cases with pulmonary tuberculosis and hypersensitivity reaction. In this review article we discuss the prior used methods of slow and rapid desensitization in case on non-CNS tuberculosis infections. This is the first reported case to use similar method of rapid desensitization in treatment of central nervous system infection. [ABSTRACT FROM AUTHOR]

Introduction: Drug-resistant tuberculous meningitis has been reported worldwide. Isoniazid mono-resistance is the most frequent cause of drug-resistant tuberculous meningitis, a life-threatening disease. Extensive drug-resistant tuberculous meningitis has also been reported in some isolated case reports. Areas covered: We reviewed the current literature on drug-resistant tuberculous meningitis, as well as drug-resistant tuberculosis. Expert commentary: Drug-resistant tuberculous meningitis is a life-threatening disease and needs prompt diagnosis and treatment. Xpert MTB/RIF Ultra technology can detect Mycobacterium tuberculosis and rifampicin resistance in cerebrospinal fluid (CSF) even with low numbers of bacilli. The optimum antituberculosis drug regimen for multidrug-resistant tuberculous meningitis is largely unknown as no second-line antituberculosis drug-containing regimen has been tested in a randomized controlled fashion in drug-resistant tuberculous meningitis. A combination of levofloxacin, kanamycin, ethionamide, linezolid, and pyrazinamide would be an appropriate regimen because of excellent CSF profile of most of these drugs. End TB Strategy will help in checking the increasing challenge of drug-resistant tuberculous meningitis as it aims to eliminate all kinds of tuberculosis by the year 2035. [ABSTRACT FROM AUTHOR]

Tuberculosis (TB) is one of the leading causes of mortality and morbidity in the world, especially in developing countries that account for 98 % deaths among TB cases. Although TB is primarily a disease of the lungs, extrapulmonary manifestations have been reported. Although CNS tuberculoma mostly affects immunocompromised people, it also affects healthy people at extremes of age. Imaging of intracranial tuberculoma may look like neurocysticercosis, and other ring-enhancing lesions hence imposing a diagnosis dilemma. A 13-year-old female presented with headache, convulsions, blurry vision, and gait disturbance for six months. Brain imaging showed a left cerebellar lesion with obstructive hydrocephalus. She underwent ventriculoperitoneal shunting on admission, then sub-occipital craniotomy with tumor resection one week later. Histology confirmed a diagnosis of tuberculoma. She was given anti-tuberculosis medications and she was discharged home healthy without any of the symptoms she had on admission. Although only about 1 % of active tuberculosis cases presents as CNS TB, 5–10 % of intracranial space-occupying lesions in developing countries are tuberculomas. Provisional diagnosis of tuberculoma can be made through clinical history, examination, and neuroimaging. However, it is challenging because neurocysticercosis also appears as a ring-enhancing lesion in the brain and has almost similar prevalence in low-income settings. Being immunocompetent with no history of tuberculosis or constitutional symptoms, a diagnosis of tuberculoma was only confirmed by histology. A high index of suspicion for CNS tuberculomas in TB endemic areas should be kept in patients presenting with features of intracranial space-occupying lesions regardless of the absence of risk factors. • TB commonly affect immunocompromised individuals however, immunocompetent persons can also be affected. • CNS tuberculoma is a rare site for extrapulmonary tuberculosis and it can easily be misdiagnosed • In high TB prevalent areas, CNS tuberculomas should be considered in patients with features of intracranial space-occupying lesions regardless of the absence of risk factors • Careful evaluation of the neuroradiological images with adequate clinic-radiological correlation allows for accurate diagnosis and ensures the proper care [ABSTRACT FROM AUTHOR]

Abstract Background Calvarial tuberculosis is uncommon. It usually presents as a punched out lesion with varying extend of extradural and subgaleal collection. However, typical imaging findings may be lacking and may appear as a neoplasm-like meningioma. This report details the clinical and imaging findings of a left frontal lesion which mimicked neoplasm. Clinical Presentation A 54-year-old female patient presented with decreased speech output and a gradually growing swelling on the left side of the scalp for 1 year duration. On imaging, lesion was left frontal subgaleal plane and left frontal parenchyma with different signal changes. Bony changes were minimal. Our preoperative diagnosis was a central nervous system tumor-like convexity meningioma with an extracranial growth or a dural-based sarcoma or slow-growing metastasis. The patient underwent left frontal craniotomy and excision of the lesion. Histopathology was suggestive of tuberculous granuloma. Conclusion Our report represented a case of diffuse variety of calvarial tuberculosis with significant growth into brain parenchyma which is rare. It should be kept as one of the differential diagnosis of lesions with intracranial and scalp component. Awareness will help in managing and prognosticating these lesions.

Tuberculoma involving the cavernous sinus is a rare presentation of CNS disease, with only twelve cases reported in previous literature. We report a case of a 48 year old woman who presented with a right cavernous sinus syndrome of 2 months duration. MRI showed a mass in the right cavernous sinus, and serologic workup revealed an elevated sedimentation rate and positive Quantiferon®-GOLD testing. 18-FDG PET-CT demonstrated a hypermetabolic 3 cm subcarinal lymph node, and lymph node biopsy showed caseating granuloma. Culture of lymphatic tissue grew drug-sensitive M. tuberculosis. The patient was treated with a non-standard 4-drug regimen and prednisone, with rapid improvement of symptoms and radiologic abnormalities. Total length of treatment was 12 months. In addition, we review the 12 cases found in literature, and discuss clinical features, diagnostic dilemmas, and approaches to treatment.

Tuberculoma involving the cerebellopontine angle is very rare. Preoperative neuroradiological features of such lesions may mimic neoplastic lesions. Our case presented with cerebellar features and multiple cranial nerve palsy. Neuroimaging mimicked CP angle neoplastic lesion. Antitubercular therapy and steroids resulted in significant clinical improvement and marked radiological reduction in size of the lesion. In our subcontinent a treatable infective cause like tuberculosis should be ruled out in CP angle lesions. Although rare but definitely a possibility to be considered. [ABSTRACT FROM AUTHOR]

Background Calvarial tuberculosis is uncommon. It usually presents as a punched out lesion with varying extend of extradural and subgaleal collection. However, typical imaging findings may be lacking and may appear as a neoplasm-like meningioma. This report details the clinical and imaging findings of a left frontal lesion which mimicked neoplasm. Clinical Presentation A 54-year-old female patient presented with decreased speech output and a gradually growing swelling on the left side of the scalp for 1 year duration. On imaging, lesion was left frontal subgaleal plane and left frontal parenchyma with different signal changes. Bony changes were minimal. Our preoperative diagnosis was a central nervous system tumor-like convexity meningioma with an extracranial growth or a dural-based sarcoma or slow-growing metastasis. The patient underwent left frontal craniotomy and excision of the lesion. Histopathology was suggestive of tuberculous granuloma. Conclusion Our report represented a case of diffuse variety of calvarial tuberculosis with significant growth into brain parenchyma which is rare. It should be kept as one of the differential diagnosis of lesions with intracranial and scalp component. Awareness will help in managing and prognosticating these lesions. [ABSTRACT FROM AUTHOR]