Focal Cerebral Arteriopathy and Stroke Secondary to Tuberculous Meningitis

Abstract

In countries where tuberculosis (TB) is endemic, children with tuberculous meningitis (TBM) commonly present with cerebrovascular complications such as stroke [1]. Herein, we present a patient from the United States with stroke associated with focal cerebral arteriopathy (FCA) secondary to TBM.

This 11-month-old girl presented with left hemiparesis and seizure. About 1.5 weeks before presentation, her parents noticed fatigue and decreased appetite and that she was not crawling as usual. Two days before presentation, her parents noticed decreased strength in her left arm and leg. Computed tomography of the head showed an area of hypoattenuation in the right basal ganglia and loss of gray and white matter differentiation in the right frontal cortex. While en route to our hospital, she had a seizure described as bilateral upper extremity shaking lasting 1 min, which self-resolved. On examination, she had right preferential gaze and left hemiparesis. Laboratory findings were significant for hyponatremia of 126 mEq/L. Magnetic resonance imaging of the brain (Figure 1) showed a right middle cerebral artery (MCA) distribution ischemic stroke. Magnetic resonance angiography (Figure 2) showed decreased flow in the right supraclinoid portion of the right internal carotid artery (ICA), A1 segment of the right anterior cerebral artery (ACA), and M1 segment of the right MCA and mild narrowing involving the petrous portion of the right carotid artery and carotid siphon. Her evaluation included cerebrospinal fluid (CSF) evaluation, which showed pleocytosis (235 cells/μL) with hypoglycorrhachia (11 mg/dL) and an elevated CSF protein (272 mg/dL).

Additional evaluation included CSF testing (bacterial culture, viral meningitis/encephalitis panel, herpes simplex virus polymerase chain reaction [PCR], and varicella virus PCR and antibodies) and respiratory panel for COVID-19, which were all negative. Chest computed tomography showed mediastinal and right hilar lymphadenopathy as well as nodular opacities in bilateral upper lobes with a miliary pattern.

Further family history included exposure to grandfather 1 month before his diagnosis of active TB; her grandfather had recently traveled to his native country, where TB is endemic. An interferon-gamma release assay and gastric aspirate culture were positive for Mycobacterium tuberculosis. The TB skin test was also positive. A CSF acid-fast bacilli culture was negative. She was diagnosed with FCA with right MCA stroke secondary to TBM and disseminated TB. She was treated with steroids and antitubercular therapy. Her seizures were controlled with levetiracetam and phenobarbital, which were weaned off as an outpatient. Upon the most recent follow-up at 3 years of age, she had spastic left hemiplegia, and she was able to sit independently but was not walking yet.

TB affects 1.2 million children worldwide, with an estimated 4% of TB diagnoses progressing to TBM [1-3]. The peak incidence of TBM in children is 2–4 years, with presentation ranging from nonspecific symptoms such as fever and headache to more progressive symptoms including cranial nerve palsies, focal neurological deficits, and stroke [1, 3, 4]. In the VIPS study, distal ICA was typically involved in individuals with an infection-related FCA like meningitis, as in our patient, compared with proximal MCA involvement in FCA related to other etiologies [5]. Infection should be considered in FCA involving the distal ICA, although MCA and ACA involvement is not uncommon [6]. In our patient, the imaging findings were suspicious for an infection-related FCA, which prompted an evaluation. Hyponatremia, CSF findings, and a history of exposure to a grandfather with TB guided our diagnosis for this patient.

Our patient emphasizes the imaging characteristics of an infection-related FCA. With increasing international travel and global immigration, clinicians, even in non-endemic countries, should consider TB in their differential diagnosis.

Mahesh Chikkannaiah: conceptualization, investigation, writing – original draft, writing – review and editing, methodology, visualization, supervision. Sarah G. Yu: investigation, writing – original draft, writing – review and editing. Laura D. Fonseca: writing – original draft, writing – review and editing, project administration. Ajay Goenka: writing – review and editing. Gogi Kumar: writing – review and editing, supervision.

A consent-to-disclose form was obtained from the legal guardian of the patient, authorizing the publication of the information included in this article. This case report was acknowledged by the institutional review board of the hospital (Study #2023-003, IRB# 2002722) and determined as a non-research activity.

The authors declare no conflicts of interest.