Multifaceted progressive neurotuberculosis in a single patient: from miliary tuberculomas to cortical venous infarct

Neurotuberculosis is a potentially fatal disease which requires prompt diagnosis and immediate multidrug antitubercular treatment as per international guidelines. There is evidence that the bacterial spread can continue even during therapy at least in its initial stages. We monitored our patient not only with chest X-rays but with brain MRI during the first 6 weeks. To our surprise on serial MRI, during treatment, we found several new localization of the disease in a pauci-symptomatic patient. These included vessel wall inflammation (vasculitis), arachnoiditis and hypophysitis. At 4 weeks of treatment, the patient complained of dizziness and vomiting which were first dismissed as treatment side-effects but MRI revealed multiple cortical venous hemorrhagic infarcts. We report this case to emphasize the importance of neuroimaging even in case of the most subtle symptoms and that disease can continue to progress in the initial phase of treatment which may require additional therapeutic intervention.