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A 31-year-old female presented with a 3-week history of fever and headache. CSF Ziehl-Neelsen smear microscopy revealed acid-fast bacilli, and CSF GeneXpert MTB/RIF was positive for <i>Mycobacterium tuberculosis</i> with no mutations of rifampicin resistance. Tuberculous meningitis (TBM) was diagnosed. Baseline contrast-enhanced brain magnetic resonance imaging (MRI) was unremarkable. Eight weeks later the patient developed markedly reduced visual acuity and clinical signs consistent with left 3rd and 6th cranial nerve palsies. Repeat contrast-enhanced brain MRI revealed extensive tuberculous exudate filling the basal cisterns of the brain consistent with a severe paradoxical reaction of TBM. High dose intravenous dexamethasone was administered, with visual acuity returning to near-normal over 3-4 weeks. In TBM paradoxical inflammatory reactions are common yet difficult to predict. When severe, they may result in substantial neurological morbidity and death. Prompt host directed therapies such as corticosteroids may reduce chances of permanent neurological damage.

Original publication

DOI

10.1016/j.idcr.2020.e01009

Type

Journal

IDCases

Publication Date

01/2021

Volume

23

Addresses

Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Viet Nam.