Abstract Introduction Tuberculosis (TB) remains a major global health concern. Central nervous system (CNS) involvement, particularly Tuberculous Meningoencephalitis (TBM), is the most severe form, carrying high morbidity and mortality. We present a rare and aggressive case of a young male with confirmed extensive pulmonary TB who rapidly developed life-threatening TBM, presenting with acute onset quadriparesis and urinary retention. Case Presentation A 35-year-old male from Ecuador with no known prior medical history presented with several months of progressive constitutional symptoms (fatigue, malaise, significant weight loss) that acutely worsened over four days with dizziness, vomiting, and generalized weakness. On presentation, a CT scan revealed innumerable cavitary lesions throughout both lungs (Image), highly suspicious for extensive pulmonary TB. The patient was immediately placed in airborne isolation and workup for TB was commended including sputum for AFB and Quantiferon. During his hospital stay, his neurological status declined rapidly, developing progressive bilateral upper extremity weakness that quickly advanced to quadriparesis and required Foley catheterization for urinary retention. An MRI Brain demonstrates classic findings of TBM: communicating hydrocephalus, multiple enhancing lesions in the basilar cisterns and brainstem, and leptomeningeal enhancement. The diagnosis was definitively confirmed by a positive bronchial wash culture for Mycobacterium tuberculosis complex (MTB complex). Following imaging and culture confirmation, the patient was urgently started on the four-drug anti-tuberculosis regimen (RIPE) along with high-dose Dexamethasone for CNS inflammation. Given the diagnosis of TBM complicated by hydrocephalus, he was transferred for neurosurgical intervention and specialized neurocritical care, including urgent ventriculoperitoneal (VP) shunt placement. CSF fluid was smear negative for AFB and MTB-PCR was also negative, cultures are pending. Patient was transferred to medical floors and continued on RIPE therapy. Patient is now awaiting transfer to skilled nursing facility for prolonged rehabilitation. Discussion This case highlights the aggressive and complicated nature of CNS tuberculosis. The patient’s rapid progression from non-specific constitutional symptoms to acute TBM with devastating neurological deficits (quadriparesis and hydrocephalus) underscores the necessity of maintaining a high clinical index of suspicion for disseminated TB, even in seemingly immunocompetent young adults. The involvement of the brainstem and potentially the spinal cord is the likely etiology for severe quadriparesis and obstructive uropathy. Prompt diagnosis via imaging and culture, followed by immediate anti-tuberculosis therapy and adjunctive corticosteroids, is critical to mitigating neurological damage and often necessitates urgent neurosurgical intervention for complications like hydrocephalus. This abstract is funded by: None
Ghufran et al. (Fri,) studied this question.