A rare masquerade of isolated oculomotor neuropathy

A 47-year-old male presented with unilateral, pupil-involving partial oculomotor nerve palsy—an alarming presentation often associated with posterior communicating artery aneurysm. However, magnetic resonance imaging revealed multiple ring-enhancing lesions in the midbrain, and Cerebrospinal Fluid (CSF) GeneXpert confirmed central nervous system tuberculosis (TB). The patient was treated with antitubercular therapy and corticosteroids for 18 months, but no clinical improvement was observed. This case highlights an uncommon neuro-ophthalmic manifestation of Central Nervous System (CNS) tuberculoma mimicking aneurysmal pathology. It underscores the importance of considering TB in the differential diagnosis of third nerve palsy, especially in endemic regions to enable timely imaging and treatment.