An atypical presentation of neurotuberculosis vasculitis mimicking visceral leishmaniasis

*Correspondence: [e-mail].

Abstract

Case Presentation: We present a case of an eight-year-old boy who was previously healthy and was evaluated for a three-month history of daily fever and weakness. Upon physical examination, he exhibited hepatosplenomegaly, and his laboratory results revealed a low platelet count (108,000 /microL), anemia (hemoglobin - 9,6 g/dL), and elevated C-reactive protein (30.04 mg/L). Notably, two weeks prior to the onset of his symptoms, he had traveled to Sobral-Ceará, an endemic area for visceral leishmaniasis (VL). He was admitted to the Pediatrics Ward for further investigation of possible VL. However, during his evaluation, he suddenly developed right-sided hemiparesis and lost consciousness, without any preceding headaches or other neurological symptoms. A computed tomography (CT) scan of his head was unremarkable, but his cerebrospinal fluid (CSF) analysis showed elevated white blood cell count (380 cells, 86% neutrophils), elevated lactate levels (51.36 mg/dL), and reduced glucose levels (29 mg/dL - 88 mg/dL serum). The Xpert MTB/RIF Assay - GeneXpert® test yielded positive results for Mycobacterium tuberculosis, despite negative results for mycobacterial cultures. Further screening revealed a typical pattern of miliary pulmonary tuberculosis (TB) on a chest CT scan. The patient was started on TB treatment and follow-up brain magnetic resonance imaging (MRI) revealed infarct areas in T2/FLAIR in regions supplied by the left middle cerebral artery, with accompanying leptomeningeal enhancement.

Discussion: This atypical case of neurotuberculosis presents several interesting points for discussion. Firstly, the patient did not exhibit typical pulmonary symptoms and initially showed symptoms suggestive of another infectious disease, leading to investigation for VL which was negative. Additionally, he had no known contact with individuals diagnosed with TB, had received TB vaccination, and had no prior history of recurrent infections. However, the Genexpert test, though less sensitive for CSF analysis, played a crucial role in early diagnosis and prompt initiation of treatment.

Final Comments: This case report highlights the diverse clinical manifestations of TB and emphasizes the need to consider TB in the context of persistent fever in Brazil, even in the absence of pulmonary symptoms. Early recognition and treatment are crucial in preventing complications of the disease, underscoring the importance of timely diagnosis.

Publication History

Article published online:
12 May 2025