Cerebral Vasculitis Research Articles

Abstract TMP92: Clinical Outcomes Of Surgical Clipping Versus Endovascular Coiling For Aneurysmal Subarachnoid Hemorrhage In Pediatric Patients

Background: Surgical clipping (SC) and endovascular coiling (EC) are both being utilized in the management of ruptured intracranial aneurysms in pediatric patients. However, the data regarding the comparative safety of these techniques is limited. In this study, we aimed to evaluate the clinical outcomes of SC versus EC in pediatric patients presenting with aneurysmal subarachnoid hemorrhage (SAH). Methods: Pediatric hospitalizations undergoing surgical intervention for non-traumatic SAH were identified from the Nationwide Readmissions Database, 2016-2018. Hospitalizations with the diagnoses of arteriovenous malformation, cerebral arteritis, or traumatic SAH were excluded. Logistic regression analysis was used to compare outcomes between SC and EC. Survival analysis was used to evaluate 30-day non-elective readmissions. Results: During the study period, 238 patients met the inclusion criteria (mean±SD age: 10.8±6.4 years; female: 46.8%). Of these, 81 (34.0%) patients underwent SC and 157 (66.0%) underwent EC. There were no statistically significant differences in the baseline demographics, clinical presentation, and hospital-level characteristics between the two groups. Clinical outcomes including post-operative stroke, seizures, prolonged mechanical ventilation, acute cardiac complications, venous thromboembolism, infections, length of hospital stay, in-hospital mortality, and discharge disposition were similar between the two groups, however, patients with EC were less likely to develop acute renal failure (OR: 0.2, 95% CI: 0.1-0.9). Further, 14 patients were readmitted within 30 days of discharge due to a non-elective reason (mean±SD time to readmission: 17.2±8.0 days). Patients with EC were less likely to get readmitted, however, the difference was not statistically significant (HR: 0.5, 95% CI: 0.1-2.3). While most of the readmissions were due to non-neurologic etiology, 29% were due to hydrocephalus or post-surgical complications. There was no in-hospital mortality among readmissions. Conclusions: The safety profiles of SC and EC for the treatment of aneurysmal SAH in pediatric patients were comparable. However, we identified a trend towards better clinical outcomes in patients treated with EC as compared to SC.

TLR8/TLR7 dysregulation due to a novel TLR8 mutation causes severe autoimmune hemolytic anemia and autoinflammation in identical twins.

Our study presents a novel germline c.1715G>T (p.G572V) mutation in the gene encoding Toll-like receptor 8 (TLR8) causing an autoimmune and autoinflammatory disorder in a family with monozygotic male twins, who suffer from severe autoimmune hemolytic anemia worsening with infections, and autoinflammation presenting as fevers, enteritis, arthritis, and CNS vasculitis. The pathogenicity of the mutation was confirmed by in vitro assays on transfected cell lines and primary cells. The p.G572V mutation causes impaired stability of the TLR8 protein, cross-reactivity to TLR7 ligands and reduced ability of TLR8 to attenuate TLR7 signaling. This imbalance toward TLR7-dependent signaling leads to increased pro-inflammatory responses, such as nuclear factor-κB (NF-κB) activation and production of pro-inflammatory cytokines IL-1β, IL-6, and TNFα. This unique TLR8 mutation with partial TLR8 protein loss and hyperinflammatory phenotype mediated by TLR7 ligands represents a novel inborn error of immunity with childhood-onset and a good response to TLR7 inhibition.

Levodopa Non-Responsive Parkinsonism in Tuberculous Cerebral Arteritis: A Rare Occurrence.

Levodopa Non-Responsive Parkinsonism in Tuberculous Cerebral Arteritis: A Rare Occurrence.

Cerebral vasculitis caused by Talaromyces marneffei and Aspergillus niger in a HIV-positive patient: a case report and literature review

Cerebral vasculitis is a long-standing but flourishing and fadeless research topic. Infections are a frequent cause of cerebral vasculitis, vital to diagnose due to involvement of specific anti-infection treatments. A 65-year-old man visited the hospital for his neurological symptoms without obvious inducements. After admission, radiological examination and comprehensive conventional microbiological tests (CMTs) revealed suspected intracranial infectious vasculitis. Metagenomic next-generation sequencing (mNGS) and reverse transcription-polymerase chain reaction further confirmed that his cerebral vasculitis was caused by Talaromyces marneffei (T. marneffei) and Aspergillus niger (A. niger) co-infection. The patient’s final diagnosis changed from initial herpetic encephalitis, due to the past history of cephalosome and facial herpes and non-significant antiviral therapeutic effects, to fungal cerebral vasculitis. The patient was discharged after use of targeted antifungal therapies on day 18 of his admission, and his associated symptoms disappeared completely at follow-up 3 weeks later. We first illustrated the presence of uncommon cerebral vasculitis caused by T. marneffei and A. niger in a human immunodeficiency virus-positive patient. In clinically suspected patients with infectious cerebral vasculitis, mNGS should be performed to detect potential pathogens if CMTs may not provide useful pathogenic clues, highlighting the importance of mNGS in the diagnosis and treatment of infectious diseases.

Immune Checkpoint Inhibitor-Induced Cerebral Pseudoprogression: Patterns and Categorization.

BackgroundThe inclusion of immune checkpoint inhibitors (ICIs) in therapeutic algorithms has led to significant survival benefits in patients with various metastatic cancers. Concurrently, an increasing number of neurological immune related adverse events (IRAE) has been observed. In this retrospective analysis, we examine the ICI-induced incidence of cerebral pseudoprogression and propose a classification system.MethodsWe screened our hospital information system to identify patients with any in-house ICI treatment for any tumor disease during the years 2007-2019. All patients with cerebral MR imaging (cMRI) of sufficient diagnostic quality were included. cMRIs were retrospectively analyzed according to immunotherapy response assessment for neuro-oncology (iRANO) criteria.ResultsWe identified 12 cases of cerebral pseudoprogression in 123 patients treated with ICIs and sufficient MRI. These patients were receiving ICI therapy for lung cancer (n=5), malignant melanoma (n=4), glioblastoma (n=1), hepatocellular carcinoma (n=1) or lymphoma (n=1) when cerebral pseudoprogression was detected. Median time from the start of ICI treatment to pseudoprogression was 5 months. All but one patient developed neurological symptoms. Three different patterns of cerebral pseudoprogression could be distinguished: new or increasing contrast-enhancing lesions, new or increasing T2 predominant lesions and cerebral vasculitis type pattern.ConclusionCerebral pseudoprogression followed three distinct patterns and was detectable in 3.2% of all patients during ICI treatment and in 9.75% of the patients with sufficient brain imaging follow up. The fact that all but one of the affected patients developed neurological symptoms, which would be classified as progressive disease according to iRANO criteria, mandates vigilance in the diagnosis and treatment of ICI-induced cerebral lesions.

Primary Angiitis of the Central Nervous System - Diagnosis and Management.

Primary angiitis of central nervous system (PACNS) is a rare idiopathic disorder affecting blood vessels of brain, spinal cord, and meninges, consequently leading to infarct and less frequently hemorrhage. CNS vasculitis can also occur as part of systemic vasculitis or secondary to autoimmune diseases or infections. The clinical manifestations of PACNS are non-specific and no single laboratory investigation or neuroimaging finding can reliably diagnose this condition. Histopathological evidence of transmural inflammation of blood vessels of CNS is the gold standard, but is generally pursued subsequent to conventional angiogram (CA) because of its invasive nature. The differentials of PACNS are exhaustive and include systemic vasculitis, secondary vasculitis, non-inflammatory intracranial vasculopathies, demyelination, and neoplasm. These alternative conditions can often be distinguished by history, examination, immunological testing, cerebrospinal fluid analysis, and neuroimaging. CA can detect vasculitic changes in the large to medium cerebral arteries but the specificity is low. Recent advancements in vessel wall imaging techniques have further enabled the distinction of various intracranial vasculopathies from CNS vasculitis. The disease has considerable morbidity and fatality unless timely treatment with immunosuppressive agents is initiated. Induction therapy with glucocorticoids and cyclophosphamide followed by azathioprine, mycophenolate mofetil, or methotrexate as maintenance therapy is the cornerstone of management. Biological agents such as rituximab and anti-tumour necrosis factor alpha inhibitors (infliximab and etanercept) may be used in refractory cases. This review discusses the approach to the diagnosis, determinants of outcome, and management.

Case report of an unusual manifestation of anti-GBM disease

Background: Anti-GBM disease is a small vessel vasculitis that occurs when circulating antibodies against the glomerular basement membrane develop. It is a relatively rare disease, occurring in less than two cases per million population. The usual presentation is with renal or lung manifestations or with a combination of both. Case Presentation: Our case reports a patient who presented with end-stage renal disease secondary to anti-GBM disease, with no pulmonary manifestations, who later presented with a syndrome suggesting cerebral vasculitis, that responded to immunosuppressive treatment. Conclusion: Cerebral involvement in anti-GBM disease is very rare and to our knowledge, only a few cases have been so far reported.

Intractable Progressive Cerebral Infarction with Multiple Atypical Aneurysms in Systemic Lupus Erythematosus

We report a case of intractable progressive cerebral infarction with multiple fusiform aneurysms in a 34-year-old female patient with systemic lupus erythematosus (SLE), non-responsive to massive immunotherapy. The patient visited the emergency department with dysarthria and left-sided hemiparesis that occurred 2 days before. She was diagnosed with SLE involving the brain and received 12 cycles of cyclophosphamide 12 years prior. Brain diffusion-weighted imaging showed acute infarctions involving the pons and medulla. Additionally, multifocal microbleeding-like signals in various cisternal spaces were detected using susceptibility-weighted imaging. Digital subtraction angiography revealed multiple fusiform aneurysms. Despite antithrombotic treatment with trif lusal and immunotherapies, including corticosteroids, mycophenolate mofetil, and immunoglobulins, for cerebral vasculitis associated infarction, her neurologic deficits worsened with recurrent cerebral infarction. Further investigation for accurate diagnosis and treatment is required.

Meningeal inflammation and cerebral vasculitis during acute COVID-19 with spontaneous regression.

Meningeal inflammation and cerebral vasculitis during acute COVID-19 with spontaneous regression.

CNS Vasculitis in A Patient with Systemic Lupus Erythematosus: A Case Report

CNS Vasculitis in A Patient with Systemic Lupus Erythematosus: A Case Report

Acute Posterior Multifocal Placoid Pigment Epitheliopathy Complicated by Fatal Cerebral Vasculitis.

Acute Posterior Multifocal Placoid Pigment Epitheliopathy Complicated by Fatal Cerebral Vasculitis.

Diplopia as the Initial Manifestation of Cerebral Vasculitis in a Patient with Systemic Lupus Erythematosus: Diagnostic Approach and Challenges

The term Neuropsychiatric systemic lupus erythematosus (NPSLE) encompasses all neurologic and or psychologic symptoms arising in patients with SLE after other causes have been ruled out. Cerebral vasculitis as a manifestation of NPSLE is a rare case with a very broad spectrum of clinical presentation and severity. We report a case of a female with cerebral vasculitis presenting with diplopia as its early manifestation. Diagnosing cerebral vasculitis remains challenging given that biopsy as the gold standard is an invasive procedure and may not be available in many settings. A high suspicion of diagnosis requires clinicians’ judgement in reviewing combination of detailed history taking, physical examination, neuroimaging, and other available supporting modalities.

Stroke without Cerebral Vasculopathy in Sickle Cell Disease Children: Which Causes? Which Treatment?

Sickle cell disease (SCD) is a severe hemoglobinopathy due to abnormal hemoglobin S (HbS). One of the most serious complications of SCD is cerebral vasculopathy (CV) leading to ischemic stroke in 8% of homozygous SS children without prevention strategy. Typical CV in SCD is a stenosis of one or more intracranial or cervical arteries, including internal carotid arteries, anterior cerebral arteries and middle cerebral arteries. However, several studies have reported the occurrence of stroke in SCD children in the absence of typical cerebral vasculopathy.The aim of the study is to investigate the prevalence of stroke without CV in SCD children, and to compare them to “classical” stroke (i.e in a context of typical CV) in terms of suspected etiologies, triggering events, treatment and risk of recurrence.In a large cohort of about 1500 SCD children living in Paris area, France, we recorded all the strokes occurring between 2007 and 2020, excluding venous thrombosis and PRESS Syndrome. These children were followed in a university hospital, and all benefited from early screening for cerebral vasculopathy and an adapted stroke prevention program. We considered as a “typical” stroke any new ischemic lesion of the cerebral parenchyma associated with an acute neurological syndrome occurring in the territory of a pre-existing and/or non-regressive stenosis.25 strokes occurred during the study period. 12 of them (48%) did not met the definition of a “typical” stroke related to sickle cell CV. The children with “atypical” stroke were older (9 years old +/- 4.6, vs 6.5 years old +/- 4.3 in the typical group, p = 0.0086) and less frequently of SS genotype (33% non-SS vs 8% non-SS in the typical group). They had lower leukocyte count (11.3 G/L +/- 4.6, vs 15.7 G/L +/- 2.3 in the typical group, p=0. 04) and higher hemoglobin level at the time of the stroke (11 g/dl +/- 3 vs 7.4 g/dl +/- 1.3 in the typical group, p= 0.027). 17% of atypical strokes had posterior ischemic lesions, 33% had anterior lesions and 17% had multiple systematized lesions, in counting junctional lesions. We also found 33% of ischemic lesions of the cerebellum. Considering a potential trigger of the stroke, 58% of atypical events were hospitalized in an anesthesia or intensive care unit at the time of the stroke or less than 7 days before, compared to 8% of children with a “classic” stroke (p= 0.011). The etiologies adopted by clinicians and radiologists for the atypical stroke were reversible cerebral vasoconstriction syndrome (RCVS) (Figure 1), cerebral fat embolism, hyperviscosity and vasculitis in systemic inflammatory context. The evolution in the atypical group was more favorable in terms of recurrence (0% within 2 years vs 42 % in the typical group, p= 0.045), although only 33% (3 children) of atypical strokes were still under exchange transfusion program 24 months after the stroke vs 92% in the group of typical stroke.Overall, in a cohort of SCD children with efficient stroke prevention program, atypical strokes account for nearly half of all acute ischemic neurological events, related to hyperviscosity, RVCS or inflammatory vasculitis. Physicians must be aware of the potential triggers and of the context in which such events occur. Nevertheless, stroke without CV may not require long-term transfusion program contrary to stroke with CV, given the very low risk of recurrence we highlighted. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

A Neurotoxocariasis Case Manifesting Multiple Cerebral Infarction and Eosinophilic Meningoencephalitis

Although Toxocara canis is known to cross the blood-brain barrier, central nervous system involvement is uncommon. Clinical manifestations vary and include cerebral infarction, meningoencephalitis, myelitis, vasculitis or seizure. However cerebral infarction and meningoencephalitis rarely occur simultaneously. We report a case of multiple cerebral infarction combined with eosinophilic meningoencephalitis in a patient with neurotoxocariasis. After control of increased intracranial pressure and treatment with albendazole and steroid, the patient’s clinical symptoms improved markedly.

Primary CNS Vasculitis: Radiopathological Correlation.

Primary CNS Vasculitis: Radiopathological Correlation.

Intracerebral hemorrhage due to moyamoya syndrome as a rare presentation of cerebral rheumatoid vasculitis: a case report

BackgroundCentral nervous system affection in rheumatoid arthritis is rare. The most frequently encountered neurological complications with rheumatoid arthritis are peripheral neuropathy and atlantoaxial subluxation with subsequent spinal cord compression. Cerebral rheumatoid vasculitis is not a common complication.Case presentationA 60-year-old Egyptian female with history of rheumatoid arthritis for 15 years presented with headache and receptive aphasia. Computed tomography scan of the brain showed recent intracerebral hemorrhage. Digital subtraction cerebral angiography showed moyamoya syndrome angiographic pattern as sequelae of intracranial vasculitis. The patient did well with conservative management.ConclusionCerebral rheumatoid vasculitis is rare, but can be a life-threatening condition. Early management of rheumatoid arthritis is essential to prevent such serious complication.

A brief report on incidence, radiographic feature and prognostic significance of brain MRI changes after anti-PD-1/PD-L1 therapy in advanced non-small cell lung cancer.

Neurologic immune-related adverse events (nirAEs) are uncommon but potentially lethal complications of immune checkpoint inhibitor (ICI) treatment. However, the incidence, radiographic features and prognostic significance of brain magnetic resonance imaging (MRI) changes after ICI treatment remain largely unknown. Consecutive patients with advanced non-small cell lung cancer (NSCLC) at three participating institutions receiving anti-PD-1/PD-L1 therapy from June 2017 to September 2020 were screened, and those who received brain MRI within 6weeks before ICI initiation and at least one follow-up brain MRI after ICI treatment were included. Serial brain MRI images were independently reviewed by two experienced radiologists. With a median follow-up of 13.2months, 27 (20.0%) of the 135 enrolled patients developed certain kind of brain MRI aberration. The 1-, 2- and 3-year cumulative incidence of brain MRI aberration was 17.1%, 36.3% and 52.2%, respectively. Brain MRI aberration indicative of stroke, mimicking typical white matter lesions and presenting as T2-hyperintensity suggestive of CNS vasculitis or encephalitis, was documented in 11, 9 and 4 patients, respectively. Patients with brain MRI aberration had higher clinical benefit rate (p = 0.030), longer progression-free survival (p = 0.015) and a tendency of improved overall survival (p = 0.054). Brain MRI aberrations developed after ICI treatment are not uncommon, and their manifestations vary a lot. Patients developing brain MRI aberrations tended to have better prognosis, which needed to be further investigated.

SEVERE IRON DEFICIENCY ANEMIA CAUSING PERICARDIAL EFFUSION

TOPIC: Signs and Symptoms of Chest Diseases TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pericardial effusions are caused by numerous etiologies including metabolic, cardiac disease, infection, neoplastic, or idiopathic. They may be isolated or part of a systemic illness. Severe iron deficiency anemia causing pericardial effusion has been rarely reported and is not well studied1. CASE PRESENTATION: A 48-year-old female without significant past medical history presented with shortness of breath and exercise intolerance. She reported a five-month history of menometrorrhagia with blood clots. Physical examination was significant for a grade 3 systolic murmur and pitting edema to the knees. Labs revealed a hemoglobin of 1.7 g/dL, hematocrit of 6.3%, MCV of 51, RDW of 34.2, and reticulocyte count of 0.0245. Hemolysis markers were negative. She was transfused four units of packed red blood cells. Iron studies were not collected prior to administration of the blood transfusions, and therefore, iron studies were not available for review. However, peripheral smear demonstrated hypochromic and microcytic red blood cells with anisocytosis, poikilocytosis, and cigar cells which are diagnostic of iron deficiency anemia. She received 1 g IV Dextran for her presumed iron deficiency anemia. Echocardiogram revealed a moderate-large circumferential pericardial effusion anterior and posterior to the heart without evidence of tamponade. The location of the effusion and her anemia precluded pericardiocentesis. Other rheumatologic and cardiac workup was negative. Her symptoms improved and she was transitioned to oral iron supplementation with a hemoglobin at discharge of 6.6 g/dL.Within three weeks of iron infusion, her hemoglobin normalized to 12.3 g/dL. A repeat echocardiogram three months after her presentation showed a small posterior pericardial effusion, markedly reduced from prior. During this period, she was readmitted for new onset status epilepticus, thought to be due to CNS vasculitis. DISCUSSION: In this patient, her subsequent hospitalization for seizures was highly suspicious for CNS vasculitis based on her imaging, presentation, and overall response to steroids. Brain biopsy however was negative for vasculitis. While it is possible that her pericardial effusion was related to an underlying autoimmune disorder, her initial rheumatologic work up was negative, and her pericardial effusions did resolve with treatment of her iron deficiency anemia. Iron deficiency anemia is an unlikely cause for pericardial effusion, and overall literature remains sparse with only two case reports documented2. CONCLUSIONS: Iron deficiency anemia has been associated with high output heart failure, and subsequent pulmonary arterial hypertension, which may cause pericardial effusions3. The differential diagnosis for pericardial effusion is extensive and should be considered in each clinical context with every patient. REFERENCE #1: Adler Y, Charron P, Imazio M, Badano L, Baron-Esqivias G, Bogaert J, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC). European Heart Journal 2015;36(42):2921-2964. REFERENCE #2: Lakhotia M, Singh J, Pahadia H, Kumar H, Sanghvi S. Pericardial effusion in severe iron deficiency anemia. Heart India 2014;2(3):88-90. REFERENCE #3: Rhodes CJ, Wharton J, Howard L, Gibbs JSR, Vonk-Noordegraaf AV, Wilkins MR. Iron deficiency in pulmonary arterial hypertension: a potential therapeutic target. European Respiratory Journal 2011;38(6):1453-1460. DISCLOSURES: No relevant relationships by Anita Fei, source=Web Response No relevant relationships by Desire Guthier, source=Web Response No relevant relationships by Alisha Hossain, source=Web Response No relevant relationships by Bradley Lash, source=Web Response No relevant relationships by Emily Skutnik, source=Web Response No relevant relationships by Andrew Viscusi, source=Web Response No relevant relationships by Ali Yazdanyar, source=Web Response

Value of vessel wall magnetic resonance imaging in the diagnosis and management of cerebrovascular diseases

Abstract Background Intracranial atherosclerosis, one of the leading causes of ischemic stroke, is associated with an increased risk for recurrent stroke and dementia. Objective This work was carried out to assess suspicious lesions detected by Magnetic Resonance Angiography (MRA) and Computed Tomgraphy Angiography (CTA) for further evaluation by vessel wall MRI . Patients and methods This study was conducted on 16 patients who were admitted to Ain Shams University Specialized Hospital with establilished diagnosis of stroke (11 patients with intracranial atherosclerosis, 3 patients with CNS vasculitis and 2 patients with Moya-moya disease ) performing MRI brain including magnetic resonance angiography (MRA) that showed intracranial stenosis, who then referred to Misr Radiology Center for the evaluation of intracranial vasculopathies by vessel wall MR Imaging using 3.0-tesla (T) field strengths. Results The results showed statistically significant difference between groups as regard to significant intracranial stenosis (>50%). It was prominent among moya moya disease group (100.0%) followed by intracranial atherosclerotic groups (81.8%), whereas CNS vasculitis group shows mild intracranial stenosis (0.0%). Conclusion Intracranial vessel wall MR imaging is an adjunct to conventional angiographic imaging

DISSEMINATED TB IN A PREGNANT PATIENT

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: In the United States, most cases occur in foreign-born individuals immigrating from countries with high rates of endemic TB [1]. Aggressive dissemination of tuberculosis related to pregnancy is rarely reported in the literature; the incidence of TB in pregnancy ranges between 1 and 2% [2, 3]. We report a pregnant patient with the dissemination of tuberculosis who developed CNS symptoms and was found to have numerous brain tuberculomas. CASE PRESENTATION: A 33-year-old F P1001 25+5wga, HIV-negative Haitian woman, presented with a non-productive cough and right lower quadrant pain. Patient-reported recent travel to Haiti and history of positive quantiferon test noted during the prenatal period with subsequent negative chest x-ray screening.Initially, during the admission, she started to have low-grade fevers and was saturating 96% on room air. Labs were significant for elevated LFTs and ALK-PHOS. Initial chest x-ray showed bilateral infiltrates. A follow-up chest-CT demonstrated diffuse reticulonodular pattern bilaterally with no lymphadenopathy. There was a concern for multi-systemic sarcoidosis. ACE and 1,25-(OH)2 Vitamin D levels were elevated.The hospital course was complicated by new-onset lethargy and the development of late fetal decelerations, resulting in an emergent caesarian section. Pulse dose steroids were given for presumed multisystemic sarcoidosis.Three days post-delivery, the patient endorsed persistent headaches. An acute change in mentation was noted on the neurological exam, raising concern for a CNS infection. CT head revealed non-obstructive hydrocephalus and hypodensities in the bilateral parietal regions. Follow-up MRI showed ring-enhancing lesions, along with cerebral vasculitis seen on MRA. The pathology report from the placental tissue showed necrotizing granulomatous inflammation and an abundance of acid-fast bacillus. Emergently, the patient was started on treatment for tuberculomas of the brain. DISCUSSION: Meningitis and tuberculoma are the two most common forms of intracranial tuberculosis [4]. CNS TB is uncommon in HIV-negative patients [5]. The pathogenesis of TB of the brain initially starts with a rupture of rich focus into the subarachnoid space, heralding the onset of meningitis. The subsequent development of adhesions results in neurological sequelae [6]. Cerebral imaging is essential to establish the diagnosis of and disclose hydrocephalus, basilar meningeal thickening, and tuberculomas [3]. CONCLUSIONS: Although a multidisciplinary approach was taken, we feel that the administration of pulse dose steroids allowed the reactivation of disseminated TB, ultimately resulting in our patient's demise. REFERENCE #1: Amin S, Stone D, Anderlind C. A 32-Year-Old Woman With Miscarriage, Headache, Hepatitis, and Pulmonary Disease. Chest. 2019 Apr;155(4):e101-e105. doi: 10.1016/j.chest.2018.10.001. PMID: 30955580. DISCLOSURES: No relevant relationships by Rosa Arancibia, source=Web Response No relevant relationships by Felicia Canaday, source=Web Response No relevant relationships by Andrew Doodnauth, source=Web Response No relevant relationships by Khawaja Omar, source=Web Response