Isolated Central Nervous System Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome-Case Report and...

An immunocompetent young male in his early 20s presented with a 1-month history of central chest pain, dyspepsia and significant weight loss. Initial evaluation revealed a large, deep oesophageal ulcer and extensive necrotic mediastinal lymphadenopathy. Endobronchial ultrasound-guided fine-needle aspiration of the mediastinal nodes confirmed necrotising granulomatous inflammation, suggestive of tuberculosis. Following initiation of anti-tuberculosis treatment (ATT), he initially showed systemic improvement. However, within 2 weeks, he developed drug-induced liver injury along with new-onset focal neurological deficits, including right-sided hemiparesis and vocal cord palsy. Neuroimaging revealed multiple new intracranial lesions involving the left temporal lobe, right posterior parietal region and brainstem, whilst repeat cross-sectional imaging of the chest and abdomen was suggestive of interval improvement. A diagnosis of paradoxical isolated central nervous system tuberculosis-associated immune reconstitution inflammatory syndrome was made. He was managed with high-dose systemic corticosteroids and a modified hepatoprotective ATT regimen, resulting in clinical improvement.