Disseminated Tuberculosis Presenting As Scrofuloderma and Tuberculous Meningitis With Ischemic Stroke in the Absence of a Pulmonary Disease.

Extrapulmonary tuberculosis represents a significant proportion of tuberculosis cases, and scrofuloderma is an uncommon cutaneous manifestation caused by contiguous spread from underlying structures, such as lymph nodes, bone, or joints. Its association with central nervous system involvement, particularly tuberculous meningitis, is rare and carries a high risk of morbidity and mortality if not promptly recognized. We report the case of a 69-year-old man who initially presented with painful, indurated supraclavicular and anterior thoracic skin lesions that progressed to ulceration with seropurulent discharge, clinically consistent with scrofuloderma. This was followed by intermittent low-grade fever and subsequent subacute neurological deterioration, including altered mental status, headache, somnolence, ataxia, and disorientation. On admission, he was febrile and found to have severe hyponatremia, a frequent metabolic complication of tuberculous meningitis. Cerebrospinal fluid analysis revealed lymphocytic pleocytosis, markedly low glucose, and elevated protein and lactate, consistent with tuberculous meningitis. Brain magnetic resonance imaging demonstrated right insular leptomeningeal enhancement and a subacute ischemic infarction in the right corona radiata, suggestive of tuberculous vasculitis. Histopathological examination and GeneXpert testing (Cepheid; Sunnyvale, CA, USA) of a skin biopsy confirmed infection with