Tuberculosis (TB) infection affects about one-fourth of the world’s population. About one percent involves the central nervous system, typically manifesting as meningitis and is associated with significant morbidity and mortality. Acute demyelinating encephalomyelitis (ADEM) is an inflammatory, typically monophasic, disorder with multi-focal neurological symptoms rarely seen in infants. There is limited information regarding the relationship between tuberculosis and ADEM, though none have been reported in the pediatric population.

An unvaccinated, 7-month-old girl born at 35 weeks gestation presented with 4 days of cough, poor oral intake, drowsiness, and unusual movements. On exam, she had general irritability, neck rigidity, fixed rightward gaze, and left hemibody hypertonicity. A naso-pharyngeal swab was positive for rhino-enterovirus by polymerase chain reaction (PCR). A biopsy of a mediastinal mass demonstrated necrotizing granulomas on histopathology with acid fast bacilli (AFB) and positive TB PCR.  Cerebrospinal fluid showed a monocytic predominant pleocytosis and elevated protein with negative AFB stain, AFB culture and TB PCR. Magnetic resonance imaging (MRI) of her brain revealed multifocal white matter T2 hyperintensities in bilateral cerebral hemispheres, right internal capsule, cerebellum and brainstem without leptomeningeal or basal enhancement. MRI of her spine showed long segment T2 hyperintensity with diffuse edema extending from the cervical spine to the T10 level. Initial and repeat MRI findings were most consistent with demyelinating lesions. She was treated with methylprednisolone 30mg/kg daily for 5 days with significant clinical improvement. She was given an 8-week prednisone taper and transferred to inpatient physiatry with full recovery.

ADEM has not been reported to be a complication of TB infection in the pediatric population. We report a case of tuberculosis infection in an infant with associated encephalitis and neuroimaging showing white matter involvement most consistent with ADEM. The patient had a full recovery following antitubercular therapy and high dose steroids.