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A 48-year-old man was brought to our unit with deteriorating consciousness but no available history. His Glasgow Coma Scale score was 11/15 (E3, V4, M4). A limited neurological examination identified neck stiffness with normal upper and lower limbs except for extensor plantar responses. Cranial nerve examination was also limited, but with no obvious ophthalmoplegia, facial weakness, wasting of muscles of mastication or jaw drop. Following intubation, he was found to have persistently elevated inflammatory markers but negative blood and urine cultures. MR scan of brain with contrast showed multiple ring-enhancing lesions and meningeal enhancement without hydrocephalus (figure 1). Cerebrospinal fluid (CSF) analysis showed a raised protein, with lymphocytosis and low glucose. Nucleic acid amplification test of CSF for tuberculosis was positive.
Contributors All authors contributed equally to this article.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned. Externally peer reviewed by Aaron Berkowitz, Los Angeles, USA.
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