An uncommon cause of young stroke

Abstract

Central nervous system tuberculosis (CNS TB) which accounts for 1-10% of all cases of TB can rarely present with cerebrovascular disease which is a serious complication. We present a young patient with an acute stroke as the first manifestation of CNS tuberculosis. 15 year boy presented with sudden left hemiplegia. He was previously well apart from a few days of loss of appetite. He additionally had unexplained neurology of a dilated, reactive pupil on the left. His CSF was infected with a lymphocytic pleocytosis, high protein and a significant sugar drop. In spite of empirical anti – meningitis therapy he deteriorated. MRI brain revealed a right basal ganglia T2 Hyper intensities which later became bilateral on T2/Flair with diffusion restriction on DWI and patchy contrast enhancement. [Fig 1and 2] He also developed autonomic instability. Empirical treatment with anti TB drugs and corticosteroids was commenced. PCR Gene-X pert subsequently confirmed the diagnosis of CNS TB. Tuberculous cerebrovascular disease is a serious complication of CNS TB. Most TBM associated brain infarcts are multiple, bilateral, symmetric, located in the deep gray matter. Infiltrative, proliferative and necrotising vessel pathologies have been described. There is some evidence that vasospasm may mediate stroke early in the course of the disease and proliferative intimal disease in later. CNS TB should be considered a cause in young stroke patients with unexplained cranial neuropathy and constitutional symptoms. A delay in diagnosis can lead to serious complications.