Incidental Papilledema Revealing Neurotuberculosis: A Case Report of a Diagnostic Challenge

Background: Tuberculosis (TB) remains a major global health problem, particularly in children, who are at higher risk of extrapulmonary and disseminated disease. Ocular tuberculosis is a rare manifestation and often presents with nonspecific signs, leading to delayed diagnosis. Case Presentation: We report the case of a five-year-old previously healthy boy presenting with a two-month history of persistent fever. Initial investigations revealed a positive tuberculin skin test and interferon gamma release assay, with chest CT findings suggestive of miliary TB. Despite negative microbiological tests, antitubercular therapy was initiated. Ophthalmologic evaluation showed preserved visual acuity, bilateral mild papilledema, and multifocal chorioretinitis. Neuroimaging confirmed central nervous system involvement with disseminated tubercular lesions. Fundus examination revealed grade 1 papilledema and chorioretinal lesions. Ocular ultrasound demonstrated an increased optic nerve sheath diameter consistent with intracranial hypertension. Brain MRI showed intra-axial tubercular dissemination. Extensive infectious and immunological testing excluded alternative diagnoses. The patient received prolonged multidrug antitubercular therapy, including isoniazid, rifampicin, ethambutol, pyrazinamide, amikacin, levofloxacin, and corticosteroids. Treatment was continued for a total of 15 months. Ocular findings regressed within two months, and complete systemic resolution was achieved by 21 months. At a five-year follow-up, the patient remained in good health with normal neurodevelopment and no disease recurrence. Conclusions: This case underscores the importance of considering ocular TB in children with prolonged fever and subtle ocular findings. Early ophthalmologic evaluation and prompt initiation of antitubercular therapy are essential to prevent severe complications and ensure favorable outcomes.