Stroke thrombolysis in tuberculous meningitis

Area of Science:

• Neurology
• Infectious Diseases
• Oncology

Background:

• Tuberculous meningitis (TBM) is a severe form of extrapulmonary tuberculosis.
• TBM can present with diverse neurological symptoms, sometimes mimicking other conditions like stroke.
• Cervical lymphadenopathy can be an indicator of disseminated tuberculosis.

Purpose of the Study:

• To report a unique case of tuberculous meningitis presenting as ischemic stroke.
• To highlight the diagnostic challenges and successful management of TBM.
• To emphasize the importance of considering TBM in patients with stroke-like symptoms and lymphadenopathy.

Main Methods:

• Case report of a woman in her 30s with sudden neurological deficits.
• Initial workup included CT brain, CT angiogram, and NIHSS scoring.
• Subsequent investigations involved MRI of the head and cervical lymph node biopsy.
• Treatment included thrombolysis for presumed ischemic stroke, followed by anti-tuberculous therapy and steroids.

Main Results:

• The patient initially presented with symptoms consistent with ischemic stroke (NIHSS 8), improving after thrombolysis.
• Recurrent neurological deterioration with fever and seizures occurred.
• MRI revealed leptomeningeal enhancement, and lymph node biopsy confirmed granulomatous lymphadenitis suggestive of TBM.
• Combined treatment for ischemic stroke and TBM resulted in good clinical recovery.

Conclusions:

• Tuberculous meningitis can present atypically as ischemic stroke, posing diagnostic challenges.
• Early recognition of TBM, supported by imaging and biopsy, is crucial for effective management.
• Multimodal treatment addressing both the stroke and TBM components is essential for favorable outcomes.