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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.

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]

Key Clinical Message Tuberculous brain abscess (TBA) in a child was initially misdiagnosed as glioma. Two craniotomies, abscess drainage, and anti‐tubercular therapy led to recovery. Pontine TBA, though rare and atypical, can have better outcome with timely intervention.

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.)

Tuberculous brain abscess (TBA) in a child was initially misdiagnosed as glioma. Two craniotomies, abscess drainage, and anti-tubercular therapy led to recovery. Pontine TBA, though rare and atypical, can have better outcome with timely intervention., Competing Interests: The authors declare no conflicts of interest., (© 2024 The Author(s). Clinical Case Reports published by John Wiley & Sons Ltd.)

Primary cerebral lymphoma in immunocompromised patients is rare and challenging to diagnose. Its presentation can have similarities with other opportunistic diseases like cerebral toxoplasmosis and tuberculoma, to name a few, which may affect the subsequent management. Here, we report a case of a gentleman with human immunodeficiency virus (HIV) who presented with clinical features of fever, confusion, and generalized lethargy. His imaging features mimicked those of central nervous system (CNS) tuberculosis (TB), and he was treated for one. Unfortunately, the patient failed to respond to the anti-tuberculosis treatment and continued to deteriorate eventually succumbing to his illness. Brain histopathology biopsy confirmed the diagnosis of diffuse large B-cell lymphoma. We aim to illustrate the importance of a high index of suspicion with timely action taken whenever the anticipated finding or response to treatment is not observed. Multiple imaging modalities coupled with biochemistry and histopathological investigations should be considered in discriminating competing diagnoses., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. 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, Muhd Yazid et al.)

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., (Copyright © 2024 Copyright: © 2024 Neurology India, Neurological Society of India.)

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]

Mycobacterium Tuberculous (MTb) meningitis is a rare manifestation of extrapulmonary tuberculosis (Tb) but remains the most common form of Central Nervous System (CNS) manifestation of tuberculosis. It is associated with significant morbidity and mortality yet difficult to diagnose given the low sensitivity and specificity of diagnostic testing with cerebral spinal fluid (CSF) analysis which typically shows CSF findings of lymphocytic pleocytosis, elevated protein, and low glucose and is confirmed by acid fast bacillus (AFB) culture. Here, we describe a case of severe meningoencephalopathy in the setting of disseminated tuberculosis with atypical radiological findings of tuberculoma.

IntroductionCurrent diagnostic methods used in Central Nervous System Tuberculosis (CNS TB) are limited by the paucibacillary nature of this form of tuberculosis. Posterior pituitary bright spot (PPBS) refers to an area of T1 hyperintensity in the posterior pituitary in MR imaging of the brain. It is found in 80-90% of healthy children and adults. In children with CNS TB, nearly half have absence of PPBS. This finding has not been described in adults. Our study looked for absence of PPBS in MR imaging and its association with CNS tuberculosis.ObjectiveTo study prevalence of the absence of PPBS in patients with CNS tuberculosis when compared to a control group of normal patients.MethodsThis was a retrospective case-control study of 100 patients with CNS tuberculosis and 200 controls (matched in 1:2 ratio) of patients with normal MRI brain. The MRI images were presented to a blinded radiologist in a randomised sequence to report for absence of PPBS. The data was subsequently analysed to look for association of absence of PPBS with CNS tuberculosis.ResultsAbsence of PPBS (cases (47%), controls (8.5%)) was significantly associated with CNS tuberculosis in (Odds ratio-7.90, 95%CI 4.04-15.44, P-valueConclusionAbsence of PPBS is significantly associated with CNS tuberculosis and could be a relatively simple diagnostic aid in the diagnosis of CNS tuberculosis.

Introduction: Current diagnostic methods used in Central Nervous System Tuberculosis (CNS TB) are limited by the paucibacillary nature of this form of tuberculosis. Posterior pituitary bright spot (PPBS) refers to an area of T1 hyperintensity in the posterior pituitary in MR imaging of the brain. It is found in 80–90% of healthy children and adults. In children with CNS TB, nearly half have absence of PPBS. This finding has not been described in adults. Our study looked for absence of PPBS in MR imaging and its association with CNS tuberculosis. Objective: To study prevalence of the absence of PPBS in patients with CNS tuberculosis when compared to a control group of normal patients. Methods: This was a retrospective case-control study of 100 patients with CNS tuberculosis and 200 controls (matched in 1:2 ratio) of patients with normal MRI brain. The MRI images were presented to a blinded radiologist in a randomised sequence to report for absence of PPBS. The data was subsequently analysed to look for association of absence of PPBS with CNS tuberculosis. Results: Absence of PPBS (cases (47%), controls (8.5%)) was significantly associated with CNS tuberculosis in (Odds ratio-7.90, 95%CI 4.04–15.44, P-value<0.0001). The specificity, sensitivity, positive predictive value and positive likelihood ratio are 91.5%, 47%, 73.4% and 5.53 respectively. Adding of absence of PPBS as an additional radiological feature in diagnosis of CNS TB increased the sensitivity from 77% to 84%. Conclusion: Absence of PPBS is significantly associated with CNS tuberculosis and could be a relatively simple diagnostic aid in the diagnosis of CNS tuberculosis. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVE: Central nervous system (CNS) tuberculosis (TB) is one of the extrapulmonary manifestations of mycobacterium tuberculosis. Cerebrovascular accidents and cerebral abscesses in children constitute 5 to 18.7% of all cases. Therefore, a child with congenital heart disease (Tetralogy of Fallot) and neurological manifestations consistent with brain abscess and suffered from CNS tuberculosis. CASE PEPORT: The patients is a 10-year-old boy with Tetralogy of Fallot who underwent ceftriaxone, vancomycin and anticonvulsant treatments with initial suspicion of central nervous system infection and with symptoms of fever, seizures and decreased consciousness. Due to observation of cerebral edema and several lesions in brain parenchyma in CT scans in the form of abscess, corticosteroid and metronidazole was added to the treatment process and the patient underwent cerebrospinal fluid analysis. Considering low sugar of cerebrospinal fluid, improved brain image and at the same time, lack of clinical recovery, we suspected mycobacterium tuberculosis. Therefore, the cerebrospinal fluid PCR was sent and the experimental anti-tuberculosis treatment started. Finally, the result was positive in terms of mycobacterium and anti-tuberculosis treatment continued. CONCLUSION: Tuberculosis as the cause of disease manifestations in endemic areas should always be taken into consideration. To justify patient symptoms with more common causes, one should not discard other diagnoses; because early diagnosis of CNS tuberculosis prevents certain death.

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.

Myelopathy in central nervous system tuberculosis is notorious for poor outcomes, determined by the severity of inflammation and cord level involved. Acute-onset quadriplegia or paraplegia in these cases represents a neuro-emergency. We report a young female with disseminated tuberculosis who presented with acute onset flaccid quadriparesis with loss of bladder and bowel function. Imaging helped identify the extensive involvement of the neuraxis. We propose that, in addition to anti-tubercular therapy, high-dose corticosteroids such as pulse methylprednisolone may result in a meaningful improvement and show greater rapidity of response in cases of severe central nervous system inflammation such as arachnoiditis or myelopathy.