A 22-year-old Indian male who was previously healthy, presented to the emergency department (ED) at our acute care hospital with one-week history of subjective fever, cough, and weight loss. Clinical examination was generally unremarkable, including a normal temperature, but with reduced breath sounds at the right lung base. Hematological, biochemical parameters including inflammatory markers were unremarkable, including ESR of 22 mm/h, but TB QuantiFERON assay was positive. Chest radiograph (Fig. 1) revealed faint right lower zone consolidation with minimal pleural effusion. The patient was initially assessed as a possible case of community-acquired pneumonia, but clinical deterioration with nausea, vomiting, headaches, and confusion, prompted further evaluation. Brain CT scan was unremarkable while lumbar puncture and CSF analysis demonstrated significant lymphocytic pleocytosis with 300 cells with 90 % lymphocytic predominance combined with low CFS glucose at 1.7 mmol/l (normal 2.22-3.8 mmol/L), high CSF protein at 1.98gm/dl (normal 0.15-0.45gm/dl). Microscopy showed no organisms, while bacterial cultures were negative. The diagnosis of disseminated TB with TBM was supported by a positive CSF GeneXpert MTB/RIF PCR assay from sputum and CSF showing no preliminary resistance, confirmed upon culture as a fully sensitive Mycobacterium Tuberculosis. The patient was started on conventional quadruple regimen including Rifampicin, Isoniazid, Pyrazinamide and Ethambutol with adjuvant tapering doses of steroid therapy planned for 12-month duration. The patient made a significant clinical response with reversal of all symptoms up to discharge with no residual complications.
One month following discharge, the patient presented to the ED with intense acute headache and vomiting. Physical examination was unremarkable with no neurological deficit. Urgent CT head revealed acute subarachnoid hemorrhage (Fig. 2). Further assessment with brain CT angiogram, Magnetic Resonant Imaging, and angiogram (MRI/MRA) confirmed left tempo-partial subarachnoid hemorrhage together with probable left middle cerebral artery infective aneurysm (Fig. 3). The patient underwent urgent craniotomy with warping of the left aneurysm, followed by embolization. Despite the grave implications, all the patient acute symptoms resolved, followed by a short period of rehabilitation to continue remaining therapy. Follow up showed no residual neurological sequelae.