Atypical Presentations of Central Nervous System Tuberculosis at a Tertiary Care Center: Case Series

This case series highlights three patients with unusual central nervous system (CNS) tuberculosis (TB) manifestations, diagnosed at the Department of Medicine and Neurology, Moti Lal Nehru Medical College, Prayagraj, India, between January and November 2024. The cases underscore the diagnostic challenges of atypical CNS TB and the importance of an integrated diagnostic approach combining clinical, radiological, and laboratory findings. A 35-year-old male presented with sudden-onset right-sided weakness. Imaging revealed intracranial hemorrhage (ICH) in the left parietal region without vascular anomalies. Cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis, elevated protein, and adenosine deaminase (ADA), while the interferon-gamma release assay was positive. He was diagnosed with CNS TB presenting as ICH secondary to vasculitis. A 49-year-old male developed left-hand weakness. Imaging showed a left parietal infarct. CSF analysis revealed lymphocytic pleocytosis with elevated protein and ADA. Pulmonary TB was suspected based on a chest X-ray. He was diagnosed with stroke secondary to tubercular CNS vasculitis presenting as pseudomedian nerve palsy. A 32-year-old male presented with sudden-onset bilateral lower limb weakness and sensory loss. Magnetic resonance imaging (MRI) spine findings were suggestive of a normal spine but with paraspinal muscle hyperintensity. CSF analysis was normal, and the interferon-gamma release assay was positive. Antitubercular therapy and steroids improved motor function, leading to a diagnosis of MRI-negative paraplegia secondary to tubercular myeloradiculitis. These cases demonstrate the varied and atypical manifestations of CNS TB, including ICH, stroke mimicking nerve palsy, and MRI-negative paraplegia. Prompt recognition and treatment are crucial to improve outcomes in such rare presentations.