Authors’ active participation in multidisciplinary treatment plan of care and subsequent chart review regarding patient’s hospital stay in a neurocritical care unit from 8/2017-4/2018.

A 38-year-old man with no past medical history presented with three weeks of headache and vertical diplopia. Physical exam was normal with the exception of trochlear nerve palsy. Initial CSF analyses were unremarkable. MRI brain showed scattered contrast-enhancing lesions. Demyelinating disease was suspected, so patient was discharged on steroids. One month later, he was readmitted with worsening symptoms. Repeat CSF analysis showed elevated WBC (693), protein (161), and low glucose (10). Repeat MRI brain showed worsening of enhancing lesions, and T-spot in serum was positive. RIPE therapy was started, and CSF cultures were positive for Mycobacterium tuberculosis.

Clinical course was complicated with SIADH, ischemic strokes of brain and spine due to vasculitis, and obstructive hydrocephalus with severe inflammation requiring placement and frequent exchange of three simultaneous EVDs: bilateral frontal and bilateral temporal in rotating order, and later placement of two VP shunts. After 8 months admitted in the hospital, he was discharged to inpatient rehabilitation for treatment of profound neurological sequelae.

This case report demonstrates the varied clinical spectrum of Tuberculous Meningitis with an unusual initial presentation of headache and cranial nerve palsy, followed by devastating clinical progression and obstructive hydrocephalus requiring placement of multiple simultaneous EVDs. Even with treatment, morbidity and mortality remain high.