Abstract

A 25-year-old woman presented to the Centre for Tropical Diseases, Ho Chi Minh City, Vietnam, with a 1 month history of headache, fever, and vomiting. On examination her Glasgow coma score was 14/15. Her neck was stiff, and she had a right lateral rectus palsy (Fig. 1). The cerebrospinal fluid (CSF) had excessive white cells (300 × 10³/mL cells, 70% lymphocytes, 30% neutrophils) with an elevated protein (255 mg/dL) and a low CSF : blood glucose (0.22). Acid-alcohol fast bacilli were seen in the CSF (Fig. 2). A chest x-ray revealed a diffuse, fine, nodular pattern, consistent with miliary tuberculosis. Brain MRI was performed which showed multiple, small, enhancing lesions, considered to be representative of disseminated cerebral tuberculosis (Fig. 3). Treatment was started with isoniazid, rifampicin, pyrazinamide, and streptomycin. She made an uncomplicated recovery and the MR scan abnormalities resolved (Fig. 4).