Multiple presentations of drug-resistant central nervous system tuberculosis: a case report.

Introduction and importance: Central nervous system tuberculosis (CNS-TB) is a severe manifestation of Case presentation: A 19-year-old woman with a history of systemic lupus erythematosus, treated with prednisolone and methotrexate for the past 2 years, was diagnosed with isoniazid-resistant tuberculous meningitis and multiple intracranial tuberculomas. After 4 weeks of antitubercular treatment (ATT), she experienced progressive quadriparesis, lethargy, seizures, and fever. Brain and cervical spine MRI revealed tuberculous ventriculitis and a C3-C5 intramedullary tuberculoma. The ATT led to a paradoxical neurological decline and the emergence of new lesions, consistent with tuberculous immune reconstitution inflammatory syndrome (TB-IRIS). Additionally, electrodiagnostic studies indicated the possibility of Guillain-Barré syndrome (GBS). She was referred for cervical spinal cord decompression while continuing isoniazid-sparing ATT and high-dose corticosteroids. Her neurological condition improved, and a follow-up MRI conducted 2 years later showed radiologic resolution. Clinical discussion: This case underscores the diagnostic challenges of CNS-TB in an immunocompromised patient, particularly when TB-IRIS, ventriculitis, intramedullary tuberculoma, and GBS co-occur. A positive outcome required timely identification of paradoxical worsening and immunological reactions, meticulous exclusion of alternative diagnoses, and integrated medical and surgical interventions. Conclusion: The emergence of new neurological lesions after the initiation of ATT in patients with CNS-TB, especially those receiving immunosuppressive therapy, necessitates consideration of TB-IRIS. Prompt imaging, evaluation of alternative diagnoses, and interdisciplinary management may improve outcomes.