Intracranial Microhemorrhages in a Patient With Tubercular Meningitis (TBM): A Case Report

Intracranial tuberculosis (TB) is the most serious form of systemic TB and constitutes an important cause of morbidity and mortality in underdeveloped countries. Central nervous system TB is a difficult diagnosis to make, and treat, especially in the developing nations. Intracranial hemorrhage is one of the rare complications of intracranial TB. We are reporting a case of a 70-year-old male patient who presented to the neurology ward with complaints of persistent high-grade fever associated with significant weight loss, night sweats, and hemolysis for two months. Cerebrospinal fluid analysis was suggestive of tubercular meningitis. He was started on first-line antitubercular therapy. After two weeks, he developed respiratory distress, and invasive mechanical ventilation was started. He was then referred to the Intensive Care Unit of the Critical Care Medicine department. Susceptibility weighted images magnetic resonance imaging (MRI) revealed multiple nodular and ring-enhancing lesions with multifocal areas of microhemorrhages in the brain parenchyma, and leptomeningeal enhancement in bilateral sylvian, perimesencephalic, prepontine and cerebellopontine angles. A tracheostomy was performed. He also developed septic shock for 72 hours, secondary to Pseudomonas aeruginosa and Acinetobacter baumannii ventilator-associated pneumonia, and Klebsiella bacteremia for which intravenous noradrenalin, Carbapenem and Colistin were administered. The patient improved within eight weeks. Our case presented with altered sensorium for the past three to four days but generally, there are other common features like headache, seizures, focal neurological deficit, and raised intracranial pressure. MRI findings of caseating tuberculomas reveal isointense to hypointense signals on both T2 and T1 weighted images with ring enhancement, which are in resemblance with the MRI findings of our case.