A 20-year-old male, born in Ecuador, without any antecedents of significance, presented with 3 months of non-productive cough. By history there was also unquantified weight loss, asthenia, intermittent fever and night sweats. Two weeks before admission he had exacerbation of fever, lower limb weakness, severe headache, inability to walk, and urinary incontinence. Vital signs revealed a 39  C fever. General physical examination showed poor general condition, and presence of crackles in both lungs. Neurological examination showed neck stiffness, positive Brudzinski and Kernig's signs, arreflectic lower limbs, paraparesis in both lower limbs (strength 0/5 according to the Medical Research Council grade), and a positive Babinski sign.
Routine blood tests were normal. HIV and VDRL serologies were negative. Chest X-ray showed evidence of diffuse interstitial micronodular pattern compatible with military TB, while the CT scan showed the similar pattern plus a 18 mm cavitary lesion on in the left upper lung. Brain CT scan showed no pathological findings. Cerebrospinal fluid (CSF) analysis revealed glucose 5.4 mg/dL, proteins 131.4 mg/dL, white cells 87 mm3 (polymorphonuclear 60%, mononuclear 40%) red cells 280 mm3, and negative India ink staining.
Considering the possibility of TB meningitis, the patient was empirically treated for TB initially with isoniazid 300 mg, rifampicin 600 mg, pyrazinamide 1100 mg, and ethambutol 1600 mg daily. Due to the presence of paraparesis, there was a suspicion of transverse myelitis, so dexamethasone 8 mg was administered IV every 8 h. Ceftriaxone 2 g twice a day for 7 days was added to cover other possible bacterial meningitis.
Subsequently sputum AFB smear result was positive and cerebral magnetic resonance imaging (MRI) showed a right cerebellar nodule, compatible with tuberculoma (Fig. 1). Spinal cord MRI (done after treatment initiation) revealed intramedullary T1, T2 and STIR hyper intense signals extending from T7 to T9 segments; confirming the suspicion of transversal myelitis (Fig. 2).
At 30 days after the spinal tap, the result of CSF culture was positive for Mycobacterium tuberculosis. At 19 days after treatment initiation, the patient fully recovered lower limbs sensitivity and motor capacity. Soon afterwards, the patient was discharged and continued TB treatment as an outpatient for one year, including oral corticosteroids during 2 months, without any adverse effects of pulsed corticosteroid therapy. One month after discharge, the patient was able to walk alone. Two months after treatment initiation, the patient was completely recovered without any residual neurological deficit.