Multifocal Vasculitic Acute Ischemic Stroke Secondary to Tubercular Meningitis with Caseating Parietal Tuberculoma and Cavitary Pulmonary Tuberculosis Co-morbid with Alcohol Dependence: A Rare Clinical Intersection

Abstract

Background: Tubercular meningitis (TBM) is the most severe form of central nervous system tuberculosis, and its course is frequently complicated by vasculitis, tuberculomas, and ischaemic infarcts. When acute vasculitic cortical-subcortical infarcts occur alongside active cavitary pulmonary tuberculosis and chronic alcohol dependence, both diagnostic reasoning and day-to-day management become considerably more difficult. Case Description: A 49-year-old man receiving anti-tubercular therapy (ATT) for pulmonary tuberculosis, with a 20-year history of heavy alcohol use, presented with sudden involuntary movements of all four limbs, generalised weakness, and slurred speech. He was drowsy but rousable, with severe dysarthria, left-sided hypertonia, and an extensor left plantar response. Contrast-enhanced brain MRI showed features of TBM, a well-defined ring-enhancing caseating tuberculoma with central liquefaction (~2.0 × 1.0 × 2.0 cm) in the left parietal lobe, and acute multifocal cortical-subcortical vasculitic infarcts in the left insular cortex and left temporo-parietal lobes. CSF analysis showed early neutrophil-predominant pleocytosis (52 cells/cumm; 85% neutrophils and 11% lymphocytes), raised protein (48.5 mg/dL), borderline glucose (45.0 mg/dL), and elevated adenosine deaminase (ADA) of 12.0 U/L. Chest imaging revealed cavitary consolidation with air-fluid levels in the right lung and bilateral consolidation. He was admitted to the ICU for airway protection and subsequently developed alcohol withdrawal delirium, which was controlled with haloperidol and quetiapine. Pulsed corticosteroids, a modified ATT regimen, mannitol, antiplatelet therapy, and thiamine repletion resulted in marked clinical improvement. Conclusion: This case highlights how early neuroimaging and CSF biomarkers can identify uncommon vascular complications of neurotuberculosis when microbiological confirmation is elusive. Managing severe TBM alongside cavitary pulmonary disease and alcohol withdrawal delirium requires close multidisciplinary coordination and an adaptive management plan as complications arise.