Multiple presentations of drug-resistant central nervous system tuberculosis: a case report.

INTRODUCTION AND IMPORTANCE: Central nervous system tuberculosis (CNS-TB) is a severe manifestation of Mycobacterium tuberculosis infection that can cause substantial morbidity and mortality. Tuberculous ventriculitis and intramedullary tuberculoma are two rare complications, and their coexistence poses significant diagnostic and therapeutic challenges. CASE PRESENTATION: A 19-year-old woman with a history of systemic lupus erythematosus, treated with prednisolone and methotrexate for the past 2 years, was diagnosed with isoniazid-resistant tuberculous meningitis and multiple intracranial tuberculomas. After 4 weeks of antitubercular treatment (ATT), she experienced progressive quadriparesis, lethargy, seizures, and fever. Brain and cervical spine MRI revealed tuberculous ventriculitis and a C3-C5 intramedullary tuberculoma. The ATT led to a paradoxical neurological decline and the emergence of new lesions, consistent with tuberculous immune reconstitution inflammatory syndrome (TB-IRIS). Additionally, electrodiagnostic studies indicated the possibility of Guillain-Barré syndrome (GBS). She was referred for cervical spinal cord decompression while continuing isoniazid-sparing ATT and high-dose corticosteroids. Her neurological condition improved, and a follow-up MRI conducted 2 years later showed radiologic resolution. CLINICAL DISCUSSION: This case underscores the diagnostic challenges of CNS-TB in an immunocompromised patient, particularly when TB-IRIS, ventriculitis, intramedullary tuberculoma, and GBS co-occur. A positive outcome required timely identification of paradoxical worsening and immunological reactions, meticulous exclusion of alternative diagnoses, and integrated medical and surgical interventions. CONCLUSION: The emergence of new neurological lesions after the initiation of ATT in patients with CNS-TB, especially those receiving immunosuppressive therapy, necessitates consideration of TB-IRIS. Prompt imaging, evaluation of alternative diagnoses, and interdisciplinary management may improve outcomes.