Paucibacillary Tuberculous Meningitis with Clinical-Radiological Dissociation: A Diagnostic Challenge

Tuberculous meningitis (TBM) typically presents with infection-related symptoms and biomarkers. We report a diagnostically challenging case of a 63-year-old woman with newly diagnosed diabetes who presented with stroke-like onset (hemiparesis, aphasia) but completely lacked typical infectious symptoms and signs. Neuroimaging features and near-normal cerebrospinal fluid (CSF) initially pointed to viral encephalitis, and complete resolution of symptoms following empirical treatment for viral encephalitis further confounded the diagnosis, as did coexisting venous anomalies. Notably, despite no recurrence of symptoms after treatment withdrawal, follow-up brain MRI revealed paradoxical progression of the lesions. All microbiological tests, including GeneXpert and next-generation sequencing (NGS), remained negative until meningeal biopsy demonstrated granulomatous inflammation with a single acid-fast bacillus and a positive interferon-gamma release assay (IGRA). This case underscores that TBM can masquerade as stroke, encephalitis, or non-infectious conditions, reinforcing the need for high clinical suspicion and, when indicated, tissue biopsy to establish a highly probable diagnosis.