Case Report: Tuberculous meningitis presenting with multifocal cerebral infarction and hydrocephalus in a toddler

Tuberculous meningitis is a severe pediatric emergency characterized by high rates of neurological disability, often due to hydrocephalus and inflammatory vasculopathy.

We report a previously healthy 2-year-old boy who presented with a subacute febrile illness and, after interfacility transfer, sudden-onset focal neurological deficits. Initial diffusion-weighted magnetic resonance imaging on the day of admission revealed multiple predominantly unilateral punctate acute infarcts in the posterior limb of the internal capsule, thalamus, midbrain, and temporal lobe, despite a normal large-vessel CT angiogram and the absence of initial basilar enhancement or hydrocephalus. A cerebrospinal fluid analysis showed lymphocytic pleocytosis with profound hypoglycorrhachia, and the diagnosis was supported by a positive interferon-gamma release assay, cerebrospinal fluid mycobacterial nucleic acid amplification testing, and relevant epidemiological exposure, despite a normal chest radiograph; mycobacterial culture later confirmed a Mycobacterium tuberculosis complex. Follow-up imaging 4 days later documented rapid evolution to bilateral infarcts, diffuse basilar leptomeningeal enhancement, and obstructive hydrocephalus, demonstrating the temporal progression of disease. The patient was treated with a four-drug antituberculosis regimen and adjunctive corticosteroids, with ventriculoperitoneal shunt placement for hydrocephalus, following which he showed clinical improvement.

This case highlights the phenomenon of clinical-radiological dissociation in early pediatric tuberculous meningitis, in which small-vessel vasculopathy and stroke may occur before classic meningeal enhancement is visible on imaging.

Maintaining a high index of clinical suspicion and initiating early empirical therapy based on cerebrospinal fluid profiles and epidemiological risk are crucial to preventing irreversible neurological outcomes.