Tuberculous Meningitis, Vasculitis, and Pericarditis presented by deep coma

A 32 years old male patient presented to the emergency room with complete loss of consciousness since three hours. This was after two weeks of night fever, sweating and considerable loss of weight with self-treatment by antipyretic drugs. In the last two days, the patient develops confusion and altered behavior. Clinical examination revealed high-grade fever and coma. CXR revealed mild cardiomegaly. Treatment started with intravenous fluids, antipyretics, and antibiotics. On the next day, Echocardiography revealed mild Mitral regurgitation (MR), mild pericardial effusion with thickening of the pericardial membrane that suggested pericarditis. ESR was significantly elevated (57 mm/hour). After three days of treatment without improvement, Tuberculosis (TB) proposed and laboratory investigations implemented. Brain MRI T1 weighted images with Gadolinium injection revealed basal meningeal enhancement with multiple tiny cerebral granulomas.FLAIR-weighted images revealed multiple small high signal intensity foci in bilateral temporal lobes and the basal ganglia strongly suggesting vasculitis and ischemic lesions. CSF sample and culture was done, and anti-tuberculous drugs started with IV fluids, corticosteroids, and other supportive drugs. The results of CSF culture confirmed the diagnosis of Tuberculous meningitis. After two months of continuous anti-tuberculous treatment, the patient seemed to regain consciousness. The patient continued Rifampicin tab 700 mg, Isoniazid tab 350 mg, Ethambutol tab 400 mg, Pyridoxine tab 80 mg, Aspirin tab 100 mg and other supportive drugs for six months. The patient regained full health without any mental or motor disabilities.