A70-10 A Diagnostic Mirage: Unmasking Disseminated Tuberculosis Presenting as Mild Urinary and Neurological Symptoms

Abstract Introduction Tuberculosis (TB) often presents atypically in older adults, especially when respiratory symptoms are absent, obscuring systemic dissemination. This case describes a diagnostically challenging presentation of subclinical disseminated TB with central nervous system (CNS) and pulmonary involvement in an immunocompetent patient. Description of Case A 67-year-old woman presented with low-grade fever, malaise, and one day of dysuria. On Day 1, she was afebrile, hemodynamically stable, and systemic examination was unremarkable. Laboratory findings revealed normocytic anemia (hemoglobin 9.5 g/dL), neutrophilic leukocytosis (white blood cell count 8 460/µL; neutrophils 84%), and elevated erythrocyte sedimentation rate (46 mm/hr). Urinalysis showed sterile pyuria with a negative urine culture, and empirical treatment was initiated for a presumed urinary tract infection. By Day 3, she developed a dull bifrontal headache radiating to the temporal regions without meningeal signs. Neurological examination remained normal. Lumbar puncture revealed turbid cerebrospinal fluid (CSF) with elevated protein (151 mg/dL), low glucose (7.5 mg/dL), lactate dehydrogenase (153 U/L), adenosine deaminase (9 U/L), and neutrophil-predominant cytology; malignant cells were absent. She tested positive for hepatitis C virus antibodies and negative for HIV and hepatitis B surface antigen. Chest auscultation later revealed diminished vesicular breath sounds over the bilateral mammary and infra axillary areas. Chest radiography showed diffuse lower-zone haziness with patchy left lower-lobe fibrosis. High-resolution computed tomography (HRCT) of the chest demonstrated diffuse centrilobular “tree-in-bud” nodules and basal air-space consolidations. Induced sputum cartridge-based nucleic acid amplification testing (CBNAAT) detected Mycobacterium tuberculosis. Anti-tubercular therapy was initiated, leading to progressive clinical and radiologic improvement. Discussion This case underscores the protean nature of TB in the elderly. The absence of pulmonary symptoms delayed suspicion, while integrated radiologic, cerebrospinal, and molecular findings established the diagnosis. Clinicians should maintain a high index of suspicion for occult TB in atypical presentations to enable timely diagnosis and reduce morbidity. This abstract is funded by: None