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The eye is the window to the diagnosis: tuberculous meningoencephalitis with choroidal tubercle
  1. Marco Fernandes1,
  2. Bruna Meira1,
  3. João Pedro Marto1,
  4. Ana Sofia Correia1,
  5. João Costa2,
  6. Miguel Viana-Baptista1
  1. 1Neurology, Hospital de Egas Moniz, Lisbon, Portugal
  2. 2Ophthalmology, Hospital de Egas Moniz, Lisbon, Portugal
  1. Correspondence to Dr Marco Fernandes, Neurology, Hospital de Egas Moniz, Lisbon 1349-019, Portugal; marcoa.fernandes91{at}gmail.com

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Case description

A 65-year-old Caucasian man with type 2 diabetes mellitus presented to the emergency department with subacute altered mental status, preceded by a 2-month history of progressive weight loss, anorexia and fever. He was febrile with a temperature of 38.5°C, but general medical examination was otherwise normal. He was disorientated with cognitive slowing, with no meningism or focal signs. CT scan of head was normal. Cerebrospinal fluid (CSF) examination showed a normal opening pressure (18 cm H2O), lymphocytic pleocytosis (73 cells/µL), glucose 2.9 mmol/L (26% of glycaemia), and protein 0.93 g/L. CSF smear found no organisms on Gram or Ziehl–Neelsen stain. We started empirical treatment for meningoencephalitis with intravenous ampicillin, ceftriaxone and acyclovir, but there was no clinical improvement in the following days.

MR scan of brain showed scattered white …

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