Tuberculous Meningitis Complicated With Deep Sylvian Cerebral Infarction: About an Immunocompetent Patient With HIV-AIDS

Tuberculous Meningitis Complicated With Deep Sylvian Cerebral Infarction: About an Immunocompetent Patient With HIV-AIDS | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Tuberculous Meningitis Complicated With Deep Sylvian Cerebral Infarction: About an Immunocompetent Patient With HIV-AIDS Muriel Amon Tanoh, Arlette Désirée Aka, Christian Abel Tanoh, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3268862/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract INTRODUCTION Neuromeningeal tuberculosis is the most common form of extra-pulmonary tuberculosis in developing countries. It is the most serious form of Mycobacterium tuberculosis infection. Vascular complications of tuberculous meningitis involve functional prognosis of patients. OBSERVATION In our daily practice, we frequently encounter cases of cerebral infarction associated with neuromeningeal tuberculosis in the infectious etiological balance. We report the case of an HIV immunocompetent patient hospitalized for neuromeningeal tuberculosis complicated with ischemic stroke. It was a 39-year-old patient, right-handed, admitted to the Neurology department of University Hospital of Cocody in whom the diagnosis of neuromeningeal tuberculosis was retained. She received treatment for tuberculosis in emergency. On the seventh day of hospitalization, she suddenly presented with a massive motor deficit of the left hemibody. The MRI performed was compatible with meningoencephalitis associated with recent deep right Sylvan ischemia foci. The evolution was marked by partial recovery of the left hemiplegia, right retro-bulbar neuritis, and iatrogenic hepatic cytolysis. COMMENTS Tuberculous meningitis remains today one of the most serious neurological conditions involving the vital and functional prognosis of patients. Association of cerebral infarction and tuberculous meningitis is of variable occurrence. There are reported cases in which cerebral infarction is a complication of tuberculous meningitis. On the other hand, the discovery of tuberculous meningitis can be observed in the assessment of a cerebral infarction in young subjects. Tuberculous meningovascularitis remains a rare condition in immunocompetent patients for HIV-AIDS. It results from arterial occlusion by thrombosing and obliterating endarteritis. It represents a medical emergency requiring starting anti-tuberculosis treatment. The evolution depends on the precocity of the diagnosis and the speed of treatment. CONCLUSION The sudden appearance of a neurological deficit in à patient with tuberculous meningitis even under specific treatment should suggest an ischemic stroke, especially if the symptomatology respects an anatomo-functional vascular systematization. Tuberculous meningitis- cerebral infarction- meningovascularitis- HIV immunocompetent Figures Figure 1 Figure 2 INTRODUCTION Neuromeningeal tuberculosis represents a diagnostic and therapeutic emergency. It associates a meningeal syndrome and an encephalitic syndrome. Tuberculous meningovasculitis represents one of the vascular complications responsible for ischemic stroke [ 1 ]. Tuberculous meningovascularitis is one of the vascular complications responsible for ischemic stroke. It is important to know this affection because it can raise questions about the diagnosis and the effectiveness of anti-tuberculous treatment. It is a condition resulting from obliterating arteritis involving the functional prognosis of patients with tuberculous meningitis. Through this observation, the authors highlight the rarity of tuberculous meningovascularitis in HIV-immunocompetent patients and the clinical particularity of the onset mode of this serious and disabling condition. OBSERVATION (File 040/22/1) Mrs. G. R., a 39-year-old patient with no medical history, was admitted to the Neurology department for febrile generalized tonic-clonic seizures. The clinical examination on admission revealed an infectious syndrome, a meningeal syndrome, right oculomotor paralysis due to damage of the 3rd and 6th pair of cranial nerves and an anamnestic comitial syndrome. The cranioencephalic scanner with injection of gadolinium which demonstrates radiological meningitis with contrast enhancement of the leptomeninges without parenchymal lesion or sign of involvement (Figure I). The lumbar puncture revealed lymphocytic meningitis (687 elements/mm 3 with 82% of lymphocytes) with hyperproteinorachia (2.34g/l) and hypoglycorachia (0.11g/l). The presence of acid-alcoholo-fast bacilli and Mycobacterium tuberculosis were detected at the Xpert gene of cerebrospinal fluid (CSF). The diagnosis of neuromeningeal tuberculosis was retained. Our patient received five tablets of RHZE (Rifampicin Isoniazid Pyrazinamide Ethambutol) combined with corticosteroid therapy, antiplatelet and motor physiotherapy. However, during hospitalization five days after the initiation of anti-tuberculosis treatment, it worsened with the sudden onset of left hemiplegia associated with confusional syndrome. Brain magnetic resonance imaging (MRI) confirmed the hypothesis of recent ischemia with multiple foci of deep infarcts in the territory of the right sylvian artery in B1000 diffusion sequence (Figure II). The exhaustive etiological assessment of the other causes of cerebral infarction was normal (cardiac ultrasound, ultrasound of the supra-aortic trunks, EKG and lipid assessment are normal). At three weeks of the antituberculous treatment, the evaluation of the efficacy of the treatment made it possible to note apyrexia with total disappearance of the meningeal syndrome, a partial improvement in the cytology of the CSF at 30 lymphocytes and of the proteinorachia at 1.5 g/l associated with normalization of glycorachia. The clinical monitoring made it possible to diagnose retrobulbar optic neuritis with oculalgia and visual blurring associated with ophthalmoplegia of the right eye. In addition, she presented biological abnormalities in favor of hepatic cytolysis (ASAT 127UI/l, ALAT 226UI/l) iatrogenic linked to anti-tuberculous drugs. After a collegial decision, the anti-tuberculous treatment was readjusted, maintaining five HR (Rifampicin Isoniazid) tablets, and introducing ofloxacin at a dosage of 200 mg every 12 hours. The evolution was favorable after 12 months of treatment with slow recovery of the motor deficit and other neurological symptoms [ 2 ]. COMMENTS Epidemiology In Côte d'Ivoire, as in most African countries, tuberculosis is endemic with a high susceptibility of black people to developing tuberculosis [ 3 ]. It is a major public health problem. In Côte d'Ivoire, a study conducted on neurotuberculosis in a hospital environment did not make it possible to estimate the frequency due to the small sampling, the poor technical facilities, and the difficulties of access to expensive microbiological analyses. Worldwide, the incidence of tuberculosis was estimated around twelve million of new cases in 2015, i.e., 30% concerning the central nervous system location. The world's first cases of tuberculous meningovascularitis were observed in the 17th century. We have few data in the literature related to tuberculous meningovacularitis in HIV-AIDS immunocompetent field. It affects both men and women equally. The target age group remains the population of young subjects in full activity. Hsaini and al reported four cases of tuberculous meningovascularitis with three men for one woman, all aged between 14 and 53 years old as in our observation [ 4 ]. Tuberculous meningovascularitis remains pathology of the young subject. It can occur both in immunocompromised subjects and in immunocompetent HIV patients. However, its onset in immunocompetent patients is not much listed in literature. In current practice, patients are hospitalized for a stroke in an infectious context with microbiological positivity for BK after completion of the etiological assessment. The clinical presentation remains one of the rare modes of occurrence of tuberculous meningovasculitis beginning with meningitis with damage to the cranial nerves and complicated by cerebral infarctions of the deep territory (ACM, ICA, intracranial ICA sometimes vertebrobasilar territory). It is therefore an exceptional form of meningovasculitis which can occur in a patient who has no risk factors independent of stroke but rather linked to tuberculous meningitis (TBMRIS). It is therefore a rare form of meningovascularitis that can occur in a patient with no vascular risk factor. Recent scientific work has established a possible link between the discovery of a factor called 'growth endothelial vascular factor' which remains high in the vascular involvement of tuberculous meningitis. The clinical presentation remains one of the rare modes of onset of tuberculous meningovascularitis beginning with meningitis with damage to the cranial nerves and complicated by cerebral infarction of the deep territory (MCA, ICA, intracranial ICA and sometimes vertebrobasilar territory). It is therefore an exceptional form of meningovasculitis which can occur in a patient who has no risk factors independent of stroke but rather linked to tuberculous meningitis (TBMRIS) [ 4 ]. Clinical signs Neuromeningeal tuberculosis is responsible for several neurological manifestations. Its clinical polymorphism makes positive diagnosis difficult. It may be meningitis and/or meningoencephalitis, medullary or radicular involvement, an expanding intracranial or intramedullary lesion. In our clinical case, the involvement of the cranial nerves reflected that of a preferential localization of Koch's bacillus at the base of the skull, very pathognomonic for tuberculous meningitis. This impairment of the cranial nerves, as well as motor deficit and visual impairment have been described by some authors as predictive factors for the occurrence of cerebral infarction in patients with tuberculous meningitis [ 5 ]. It is necessary to know how to think about it, to know how to evoke a tuberculous origin than the immunocompetent or dysimmune subject to HIV. Vascular involvement remains not much described in literature. The neurological signs are related to the arterial territory concerned. Most often the motor deficit that occurs suddenly remains in the foreground. Moreover, this deficit can be associated either with motor aphasia or with a minor hemisphere syndrome depending on whether the location of the lesion is on the left or right hemisphere. In our reported case, Mrs. G.R. presented with massive left hemiplegia associated with confusional syndrome probably related to the involvement of the minor hemisphere. Paraclinical signs In daily practice, a meningeal syndrome requires the realization of a lumbar puncture with analysis of CSF in emergency. Recommendations stipulate that any clear-liquid meningitis associating hypoglycorachia and hyperproteinorachia must be considered as tuberculous origin until proven otherwise. However, compared to HIV immunocompromised subjects, the level of CSF proteins is higher in HIV immunocompetent patients. The glucose concentration is similar [ 6 ]. Nowadays, the improvement of the technical platform allows the detection of Koch's bacillus by polymerase chain reaction technique correlated with the culture in order to eliminate false positives and negatives. Treatment is therefore started urgently without waiting for the results of the CSF analysis. Brain MRI has revolutionized the diagnosis of neuromeningeal tuberculosis [ 7 ]. Cerebral MRI remains the most appropriate examination to detect small areas of ischemia secondary to vasculitis. It is an aid to positive diagnosis but also allows the monitoring of cerebral parenchymal lesions. These are typically cerebral infarctions of the middle or Sylvian cerebral artery or its perforators (internal capsule), identical location also observed in our patient [ 8 ]. It may also involve the basal ganglia, which explains the damage to the cranial nerves revealed during the neurological examination in our patient. It is also possible but rare to observe a hemorrhagic infarction or intraventricular hemorrhage due to rupture of an aneurysm. Treatment The treatment of tuberculous meningovasculitis is identical to that of other tuberculosis of the brain. Long-term treatment of 12 months with anti-tuberculosis drugs is equally effective in tuberculous meningo-vascularitis in immunocompetent HIV-AIDS patients [ 9 ]. In Ivory Coast the therapeutic strategy follows international recommendations with the use of anti-tuberculosis drugs according to the therapeutic regimen proposed by the WHO and implemented as such in our patient. Several pathological mechanisms have been suggested by certain authors to explain the occurrence of this stroke, notably vasculitis, namely the phenomena of vasospasm, thrombosis and arterial compression by inflammatory exudate [ 10 ]. In high-risk patients, some authors have highlighted the role of antiplatelets in preventing stroke in patients with TBM [ 11 ]. Due to the physiopathological mechanism responsible for either thrombosis or stenosis of the vascular lumen, it is recommended to combine antiplatelet treatment and corticosteroid therapy with anti-tuberculosis treatment in inflammatory vascular disorders [ 10 , 5 , 12 , 13 ]. Evolution - prognosis Neuromeningeal damage complicated by cerebral infarctions most often has an unfavorable prognosis. The advanced stage of tuberculosis disease, basal and sylvian localization and visual impairment are among the predictive factors for the occurrence of stroke having been reported [ 5 ]. It is the cause of high morbidity and mortality with a life-threatening prognosis [ 14 , 15 ]. The functional prognosis will depend on the occurrence of neurological sequelae. The disappearance of sudden neurological manifestations should lead to the search for a vascular cause. The sudden onset of a worsening of pre-existing symptoms in a patient taking antibacterial drugs requires the search for cerebral infarction, especially since the clinical picture responds to vascular systematization with the sudden onset of a focal neurological sign [ 4 ]. The evolution depends on the speed of diagnosis and the urgent initiation of specific treatment as in our case report. Ophthalmological and hepatic examinations are necessary to monitor treatment with Ethambutol and Isoniazid respectively. In our clinical case, we noted the occurrence of NORB and toxic hepatic cytolysis. The functional prognosis will depend on irreversible ischemic parenchymal and vascular complications causing disabling motor sequelae. CONCLUSION The association of tuberculous meningitis and cerebral infarction produces a picture of tuberculous meningovascularitis. It remains a less common association in in immunocompetent subjects [ 8 , 15 ]. Vascular complications are possible during tuberculous meningitis, even when treated early and quickly [ 4 , 11 ]. It is responsible for severe, serious and disabling after-effects, hence the therapeutic urgency of appropriate treatment. Declarations Ethical approval and consent to participate The authors declare their approval and consent to participate in this scientific research project by writing this article. Consent to publication Written informed consent was obtained from all the patients and their legal guardian for publication of identifying information/images in an online open-access publication. Availability of data and materials The authors declare that they have anonymously listed the patient's clinical, paraclinical, progressive and prognostic epidemiological data from the medical file using computer equipment. Competing interests No competing interests between different authors. Funding No funding for the design of this article. Author contributions M.A.T : Data acquisition, Development of study design, drafting, editing- A.D.A : Data acquisition, proof reading, writing- C.A.T : Data acquisition, writing, editing- I.D: Data acquisition, editing, literature review- C.Y.E : Data acquisition- C.V.K : literature review- N. A. E. DS: Data acquisition- E.A.D : Study design, proof reading- B.A : Study design, review, approval Acknowledgments All thanks addressed to the Head of the Neurology Department of the University Hospital Center of Cocody and to those of the University Hospital Center of Yopougon, as well as to the Félix Houphouët Boigny University of Abidjan Côte d'Ivoire. References Morales S, Ramos W, Vílchez R, Pérez J, Alvarado M. Efficacy and safety of short- and long-term treatment regimens for tuberculous meningoencephalitis in two hospitals in Lima- Peru. Neurologia. 2011;26(4):220–6. Zhang L, Zhang X, Li H, Chen G, Zhu M. Acute ischemic stroke in young adults with tuberculous meningitis. BMC Infect Dis. 2019;362(19):1–6. Mjid M, Cherif J. Epidemiology of tuberculosis. J Clin Pneumology. 2015;71(2–3):67–72. Hsaini Y, Mounach J. Tuberculous meningovascularitis: about four cases. Neurol Rev. 2007;197(4):163. Anuradha HK, Garg RK, Agarwal A, Sinha MK, Verma R, Singh MK, Shukla R. Predictors of stroke in patients of tuberculous meningitis and its effect on the outcome. Int J Med. 2010;103(9):671–8. Cecchini D, Ambrosioni J, Brezzo C, Corti M, Rybko A, Perez M, Poggi S, Ambroggi M. Tuberculous meningitis in HIV-infected and non-infected patients: comparison of cerebrospinal fluid findings. Int J Tuberc Lung Dis. 2009;13(2):269–71. Bazin C. Tuberculosis of the central nervous system Elseiver Masson 2004. Boulahri T, Taous A. Maha Aït Berri, Imane Traibi, Abdelhadi Rouimi. Atteinte cérébro-méningée révélant une tuberculose multifocale chez un immunocompétent. PanAfrican Med J. 2016;231(25):1–6. Mapoure NY, Mbatchou NHB, Luma NH, Tchaleu CB, Ebana MC. An ischemic stroke complicating tuberculous meningitis in an immunocompetent subject: interest of the PRC. Revue de Médecine et Pharmacie. 2013, 3(2). Mai N 1, Dobbs N, Phu N, Colas R, Thao Le TP, Thuong N, Nghia H. A randomised double blind placebo controlled phase 2 trial of adjunctive aspirin for tuberculous meningitis in HIV-unfected adults. Elife. 2018;7:e33478. Wasay M, Khan M, Farooq S, Khowaja Z, Bawa Z, Ali S, Awan S, et al. Frequency and impact of cerebral infarctions in patients with tuberculous meningitis. Stroke. 2018;49(10):2288–93. Misra UK, Kalita J, Nair PP. Role of aspirin in tuberculous meningitis: a randomized open label placebo controlled trial. J Neurol Sci. 2010;293:12–7. Thwaites GE, Macmullen-Price J, Chau TTH, Mai PP, Dung NT, Simmons CP, et al. Serial MRI to determine the effect of dexamethasone on the cerebral pathology of tuberculous meningitis: an observational study. Lancet Neurol. 2007;6:230–6. Tang S, Xie Z, He Y, Zhang Y, Xie Y, Chen S, Liu Y, Wei Y, Liang Z. Acute Ischemic Stroke in Tubercular Meningitis Patients Without Conventional Vascular Risk Factors: A Retrospective Case Control Study. J Inflamm Res. 2022;15:6617–27. Sy M, Espiritu A, Pascual J. A randomised double blind placebo co ntrolled phase 2 trial of adjunctive aspirin for tuberculous meningitis in HIV-unfected adults. JAMA Netw Open. 2022;5(9):e2229282. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3268862","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":233158882,"identity":"8d004237-4039-4ee6-af74-256f276d1d87","order_by":0,"name":"Muriel Amon 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1","display":"","copyAsset":false,"role":"figure","size":71706,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe cranial brain scan with gadolinium injection which reveals radiological meningitis with leptomeningeal contrast enhancement without parenchymal lesion or sign of involvement.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3268862/v1/cb7ebdd24da15cd40c7ab461.jpeg"},{"id":43492754,"identity":"8ce7ae74-e4f1-4bb2-8ad0-7ed689aba1ee","added_by":"auto","created_at":"2023-09-21 16:18:54","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":18824,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe cranial brain scan revealed radiological meningitis with contrast enhancement of the leptomeninges without parenchymal lesion or sign of involvement.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3268862/v1/c236a3c7a06a279a52f2b2e3.jpeg"},{"id":44132161,"identity":"b5c5d353-92d5-4cd4-a4e5-f081451a61d9","added_by":"auto","created_at":"2023-10-05 12:22:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":356959,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3268862/v1/aae632c1-c7cf-4824-a5a3-c621f4469821.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eTuberculous Meningitis Complicated With Deep Sylvian Cerebral Infarction: About an Immunocompetent Patient With HIV-AIDS\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eNeuromeningeal tuberculosis represents a diagnostic and therapeutic emergency. It associates a meningeal syndrome and an encephalitic syndrome. Tuberculous meningovasculitis represents one of the vascular complications responsible for ischemic stroke [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Tuberculous meningovascularitis is one of the vascular complications responsible for ischemic stroke. It is important to know this affection because it can raise questions about the diagnosis and the effectiveness of anti-tuberculous treatment. It is a condition resulting from obliterating arteritis involving the functional prognosis of patients with tuberculous meningitis. Through this observation, the authors highlight the rarity of tuberculous meningovascularitis in HIV-immunocompetent patients and the clinical particularity of the onset mode of this serious and disabling condition.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e "},{"header":"OBSERVATION (File 040/22/1)","content":"\u003cp\u003eMrs. G. R., a 39-year-old patient with no medical history, was admitted to the Neurology department for febrile generalized tonic-clonic seizures. The clinical examination on admission revealed an infectious syndrome, a meningeal syndrome, right oculomotor paralysis due to damage of the 3rd and 6th pair of cranial nerves and an anamnestic comitial syndrome. The cranioencephalic scanner with injection of gadolinium which demonstrates radiological meningitis with contrast enhancement of the leptomeninges without parenchymal lesion or sign of involvement \u003cb\u003e(Figure I).\u003c/b\u003e The lumbar puncture revealed lymphocytic meningitis (687 elements/mm\u003csup\u003e3\u003c/sup\u003e with 82% of lymphocytes) with hyperproteinorachia (2.34g/l) and hypoglycorachia (0.11g/l). The presence of acid-alcoholo-fast bacilli and Mycobacterium tuberculosis were detected at the Xpert gene of cerebrospinal fluid (CSF). The diagnosis of neuromeningeal tuberculosis was retained. Our patient received five tablets of RHZE (Rifampicin Isoniazid Pyrazinamide Ethambutol) combined with corticosteroid therapy, antiplatelet and motor physiotherapy. However, during hospitalization five days after the initiation of anti-tuberculosis treatment, it worsened with the sudden onset of left hemiplegia associated with confusional syndrome. Brain magnetic resonance imaging (MRI) confirmed the hypothesis of recent ischemia with multiple foci of deep infarcts in the territory of the right sylvian artery in B1000 diffusion sequence \u003cb\u003e(Figure II).\u003c/b\u003e The exhaustive etiological assessment of the other causes of cerebral infarction was normal (cardiac ultrasound, ultrasound of the supra-aortic trunks, EKG and lipid assessment are normal). At three weeks of the antituberculous treatment, the evaluation of the efficacy of the treatment made it possible to note apyrexia with total disappearance of the meningeal syndrome, a partial improvement in the cytology of the CSF at 30 lymphocytes and of the proteinorachia at 1.5 g/l associated with normalization of glycorachia. The clinical monitoring made it possible to diagnose retrobulbar optic neuritis with oculalgia and visual blurring associated with ophthalmoplegia of the right eye. In addition, she presented biological abnormalities in favor of hepatic cytolysis (ASAT 127UI/l, ALAT 226UI/l) iatrogenic linked to anti-tuberculous drugs. After a collegial decision, the anti-tuberculous treatment was readjusted, maintaining five HR (Rifampicin Isoniazid) tablets, and introducing ofloxacin at a dosage of 200 mg every 12 hours. The evolution was favorable after 12 months of treatment with slow recovery of the motor deficit and other neurological symptoms [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e"},{"header":"COMMENTS","content":"\u003ch2\u003eEpidemiology\u003c/h2\u003e\u003cp\u003eIn Côte d'Ivoire, as in most African countries, tuberculosis is endemic with a high susceptibility of black people to developing tuberculosis [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It is a major public health problem. In Côte d'Ivoire, a study conducted on neurotuberculosis in a hospital environment did not make it possible to estimate the frequency due to the small sampling, the poor technical facilities, and the difficulties of access to expensive microbiological analyses. Worldwide, the incidence of tuberculosis was estimated around twelve million of new cases in 2015, i.e., 30% concerning the central nervous system location. The world's first cases of tuberculous meningovascularitis were observed in the 17th century. We have few data in the literature related to tuberculous meningovacularitis in HIV-AIDS immunocompetent field. It affects both men and women equally. The target age group remains the population of young subjects in full activity. \u003cb\u003eHsaini\u003c/b\u003e and al reported four cases of tuberculous meningovascularitis with three men for one woman, all aged between 14 and 53 years old as in our observation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Tuberculous meningovascularitis remains pathology of the young subject. It can occur both in immunocompromised subjects and in immunocompetent HIV patients. However, its onset in immunocompetent patients is not much listed in literature. In current practice, patients are hospitalized for a stroke in an infectious context with microbiological positivity for BK after completion of the etiological assessment. The clinical presentation remains one of the rare modes of occurrence of tuberculous meningovasculitis beginning with meningitis with damage to the cranial nerves and complicated by cerebral infarctions of the deep territory (ACM, ICA, intracranial ICA sometimes vertebrobasilar territory). It is therefore an exceptional form of meningovasculitis which can occur in a patient who has no risk factors independent of stroke but rather linked to tuberculous meningitis (TBMRIS). It is therefore a rare form of meningovascularitis that can occur in a patient with no vascular risk factor. Recent scientific work has established a possible link between the discovery of a factor called 'growth endothelial vascular factor' which remains high in the vascular involvement of tuberculous meningitis. The clinical presentation remains one of the rare modes of onset of tuberculous meningovascularitis beginning with meningitis with damage to the cranial nerves and complicated by cerebral infarction of the deep territory (MCA, ICA, intracranial ICA and sometimes vertebrobasilar territory). It is therefore an exceptional form of meningovasculitis which can occur in a patient who has no risk factors independent of stroke but rather linked to tuberculous meningitis (TBMRIS) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003ch2\u003eClinical signs\u003c/h2\u003e\u003cp\u003eNeuromeningeal tuberculosis is responsible for several neurological manifestations. Its clinical polymorphism makes positive diagnosis difficult. It may be meningitis and/or meningoencephalitis, medullary or radicular involvement, an expanding intracranial or intramedullary lesion. In our clinical case, the involvement of the cranial nerves reflected that of a preferential localization of Koch's bacillus at the base of the skull, very pathognomonic for tuberculous meningitis. This impairment of the cranial nerves, as well as motor deficit and visual impairment have been described by some authors as predictive factors for the occurrence of cerebral infarction in patients with tuberculous meningitis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. It is necessary to know how to think about it, to know how to evoke a tuberculous origin than the immunocompetent or dysimmune subject to HIV.\u003c/p\u003e\u003cp\u003eVascular involvement remains not much described in literature. The neurological signs are related to the arterial territory concerned. Most often the motor deficit that occurs suddenly remains in the foreground. Moreover, this deficit can be associated either with motor aphasia or with a minor hemisphere syndrome depending on whether the location of the lesion is on the left or right hemisphere. In our reported case, Mrs. G.R. presented with massive left hemiplegia associated with confusional syndrome probably related to the involvement of the minor hemisphere.\u003c/p\u003e\u003ch2\u003eParaclinical signs\u003c/h2\u003e\u003cp\u003eIn daily practice, a meningeal syndrome requires the realization of a lumbar puncture with analysis of CSF in emergency. Recommendations stipulate that any clear-liquid meningitis associating hypoglycorachia and hyperproteinorachia must be considered as tuberculous origin until proven otherwise. However, compared to HIV immunocompromised subjects, the level of CSF proteins is higher in HIV immunocompetent patients. The glucose concentration is similar [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Nowadays, the improvement of the technical platform allows the detection of Koch's bacillus by polymerase chain reaction technique correlated with the culture in order to eliminate false positives and negatives. Treatment is therefore started urgently without waiting for the results of the CSF analysis.\u003c/p\u003e\u003cp\u003eBrain MRI has revolutionized the diagnosis of neuromeningeal tuberculosis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Cerebral MRI remains the most appropriate examination to detect small areas of ischemia secondary to vasculitis. It is an aid to positive diagnosis but also allows the monitoring of cerebral parenchymal lesions. These are typically cerebral infarctions of the middle or Sylvian cerebral artery or its perforators (internal capsule), identical location also observed in our patient [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. It may also involve the basal ganglia, which explains the damage to the cranial nerves revealed during the neurological examination in our patient. It is also possible but rare to observe a hemorrhagic infarction or intraventricular hemorrhage due to rupture of an aneurysm.\u003c/p\u003e\u003ch2\u003eTreatment\u003c/h2\u003e\u003cp\u003eThe treatment of tuberculous meningovasculitis is identical to that of other tuberculosis of the brain. Long-term treatment of 12 months with anti-tuberculosis drugs is equally effective in tuberculous meningo-vascularitis in immunocompetent HIV-AIDS patients [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In Ivory Coast the therapeutic strategy follows international recommendations with the use of anti-tuberculosis drugs according to the therapeutic regimen proposed by the WHO and implemented as such in our patient. Several pathological mechanisms have been suggested by certain authors to explain the occurrence of this stroke, notably vasculitis, namely the phenomena of vasospasm, thrombosis and arterial compression by inflammatory exudate [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In high-risk patients, some authors have highlighted the role of antiplatelets in preventing stroke in patients with TBM [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDue to the physiopathological mechanism responsible for either thrombosis or stenosis of the vascular lumen, it is recommended to combine antiplatelet treatment and corticosteroid therapy with anti-tuberculosis treatment in inflammatory vascular disorders [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003ch2\u003eEvolution - prognosis\u003c/h2\u003e\u003cp\u003eNeuromeningeal damage complicated by cerebral infarctions most often has an unfavorable prognosis. The advanced stage of tuberculosis disease, basal and sylvian localization and visual impairment are among the predictive factors for the occurrence of stroke having been reported [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. It is the cause of high morbidity and mortality with a life-threatening prognosis [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The functional prognosis will depend on the occurrence of neurological sequelae. The disappearance of sudden neurological manifestations should lead to the search for a vascular cause. The sudden onset of a worsening of pre-existing symptoms in a patient taking antibacterial drugs requires the search for cerebral infarction, especially since the clinical picture responds to vascular systematization with the sudden onset of a focal neurological sign [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The evolution depends on the speed of diagnosis and the urgent initiation of specific treatment as in our case report. Ophthalmological and hepatic examinations are necessary to monitor treatment with Ethambutol and Isoniazid respectively. In our clinical case, we noted the occurrence of NORB and toxic hepatic cytolysis. The functional prognosis will depend on irreversible ischemic parenchymal and vascular complications causing disabling motor sequelae.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe association of tuberculous meningitis and cerebral infarction produces a picture of tuberculous meningovascularitis. It remains a less common association in in immunocompetent subjects [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Vascular complications are possible during tuberculous meningitis, even when treated early and quickly [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. It is responsible for severe, serious and disabling after-effects, hence the therapeutic urgency of appropriate treatment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eEthical approval and consent to participate \u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe authors declare their approval and consent to participate in this scientific research project by writing this article.\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eConsent to publication\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eWritten informed consent was obtained from all the patients and their legal guardian for publication of identifying information/images in an online open-access publication.\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe authors declare that they have anonymously listed the patient's clinical, paraclinical, progressive and prognostic epidemiological data from the medical file using computer equipment.\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNo competing interests between different authors.\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eFunding \u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNo funding for the design of this article.\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eM.A.T\u003c/strong\u003e: Data acquisition, Development of study design, drafting, editing- \u003cstrong\u003eA.D.A\u003c/strong\u003e: Data acquisition, proof reading, writing- \u003cstrong\u003eC.A.T\u003c/strong\u003e: Data acquisition, writing, editing- \u003cstrong\u003eI.D:\u003c/strong\u003e Data acquisition, editing, literature review- \u003cstrong\u003eC.Y.E\u003c/strong\u003e: Data acquisition- \u003cstrong\u003eC.V.K\u003c/strong\u003e: literature review- \u003cstrong\u003eN. A. E. DS:\u003c/strong\u003e Data acquisition- \u003cstrong\u003eE.A.D\u003c/strong\u003e: Study design, proof reading- \u003cstrong\u003eB.A\u003c/strong\u003e: Study design, review, approval\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll thanks addressed to the Head of the Neurology Department of the University Hospital Center of Cocody and to those of the University Hospital Center of Yopougon, as well as to the F\u0026eacute;lix Houphou\u0026euml;t Boigny University of Abidjan C\u0026ocirc;te d'Ivoire.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMorales S, Ramos W, V\u0026iacute;lchez R, P\u0026eacute;rez J, Alvarado M. Efficacy and safety of short- and long-term treatment regimens for tuberculous meningoencephalitis in two hospitals in Lima- Peru. Neurologia. 2011;26(4):220\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang L, Zhang X, Li H, Chen G, Zhu M. Acute ischemic stroke in young adults with tuberculous meningitis. BMC Infect Dis. 2019;362(19):1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMjid M, Cherif J. Epidemiology of tuberculosis. J Clin Pneumology. 2015;71(2\u0026ndash;3):67\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHsaini Y, Mounach J. Tuberculous meningovascularitis: about four cases. Neurol Rev. 2007;197(4):163.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnuradha HK, Garg RK, Agarwal A, Sinha MK, Verma R, Singh MK, Shukla R. Predictors of stroke in patients of tuberculous meningitis and its effect on the outcome. Int J Med. 2010;103(9):671\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCecchini D, Ambrosioni J, Brezzo C, Corti M, Rybko A, Perez M, Poggi S, Ambroggi M. Tuberculous meningitis in HIV-infected and non-infected patients: comparison of cerebrospinal fluid findings. Int J Tuberc Lung Dis. 2009;13(2):269\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBazin C. Tuberculosis of the central nervous system Elseiver Masson 2004.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoulahri T, Taous A. Maha A\u0026iuml;t Berri, Imane Traibi, Abdelhadi Rouimi. Atteinte c\u0026eacute;r\u0026eacute;bro-m\u0026eacute;ning\u0026eacute;e r\u0026eacute;v\u0026eacute;lant une tuberculose multifocale chez un immunocomp\u0026eacute;tent. PanAfrican Med J. 2016;231(25):1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMapoure NY, Mbatchou NHB, Luma NH, Tchaleu CB, Ebana MC. An ischemic stroke complicating tuberculous meningitis in an immunocompetent subject: interest of the PRC. Revue de M\u0026eacute;decine et Pharmacie. 2013, 3(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMai N 1, Dobbs N, Phu N, Colas R, Thao Le TP, Thuong N, Nghia H. A randomised double blind placebo controlled phase 2 trial of adjunctive aspirin for tuberculous meningitis in HIV-unfected adults. Elife. 2018;7:e33478.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWasay M, Khan M, Farooq S, Khowaja Z, Bawa Z, Ali S, Awan S, et al. Frequency and impact of cerebral infarctions in patients with tuberculous meningitis. Stroke. 2018;49(10):2288\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMisra UK, Kalita J, Nair PP. Role of aspirin in tuberculous meningitis: a randomized open label placebo controlled trial. J Neurol Sci. 2010;293:12\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThwaites GE, Macmullen-Price J, Chau TTH, Mai PP, Dung NT, Simmons CP, et al. Serial MRI to determine the effect of dexamethasone on the cerebral pathology of tuberculous meningitis: an observational study. Lancet Neurol. 2007;6:230\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang S, Xie Z, He Y, Zhang Y, Xie Y, Chen S, Liu Y, Wei Y, Liang Z. Acute Ischemic Stroke in Tubercular Meningitis Patients Without Conventional Vascular Risk Factors: A Retrospective Case Control Study. J Inflamm Res. 2022;15:6617\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSy M, Espiritu A, Pascual J. A randomised double blind placebo co ntrolled phase 2 trial of adjunctive aspirin for tuberculous meningitis in HIV-unfected adults. JAMA Netw Open. 2022;5(9):e2229282.\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Tuberculous meningitis- cerebral infarction- meningovascularitis- HIV immunocompetent","lastPublishedDoi":"10.21203/rs.3.rs-3268862/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3268862/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eINTRODUCTION\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNeuromeningeal tuberculosis is the most common form of extra-pulmonary tuberculosis in developing countries. It is the most serious form of Mycobacterium tuberculosis infection. Vascular complications of tuberculous meningitis involve functional prognosis of patients.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOBSERVATION\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn our daily practice, we frequently encounter cases of cerebral infarction associated with neuromeningeal tuberculosis in the infectious etiological balance. We report the case of an HIV immunocompetent patient hospitalized for neuromeningeal tuberculosis complicated with ischemic stroke. It was a 39-year-old patient, right-handed, admitted to the Neurology department of University Hospital of Cocody in whom the diagnosis of neuromeningeal tuberculosis was retained. She received treatment for tuberculosis in emergency. On the seventh day of hospitalization, she suddenly presented with a massive motor deficit of the left hemibody. The MRI performed was compatible with meningoencephalitis associated with recent deep right Sylvan ischemia foci. The evolution was marked by partial recovery of the left hemiplegia, right retro-bulbar neuritis, and iatrogenic hepatic cytolysis.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCOMMENTS\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTuberculous meningitis remains today one of the most serious neurological conditions involving the vital and functional prognosis of patients. Association of cerebral infarction and tuberculous meningitis is of variable occurrence. There are reported cases in which cerebral infarction is a complication of tuberculous meningitis. On the other hand, the discovery of tuberculous meningitis can be observed in the assessment of a cerebral infarction in young subjects. Tuberculous meningovascularitis remains a rare condition in immunocompetent patients for HIV-AIDS. It results from arterial occlusion by thrombosing and obliterating endarteritis. It represents a medical emergency requiring starting anti-tuberculosis treatment. The evolution depends on the precocity of the diagnosis and the speed of treatment.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCONCLUSION\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe sudden appearance of a neurological deficit in \u0026agrave; patient with tuberculous meningitis even under specific treatment should suggest an ischemic stroke, especially if the symptomatology respects an anatomo-functional vascular systematization.\u003c/p\u003e","manuscriptTitle":"Tuberculous Meningitis Complicated With Deep Sylvian Cerebral Infarction: About an Immunocompetent Patient With HIV-AIDS","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-09-21 16:18:49","doi":"10.21203/rs.3.rs-3268862/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"213d15f9-262a-4b04-a4b8-71b9e7950e0f","owner":[],"postedDate":"September 21st, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-10-05T12:14:24+00:00","versionOfRecord":[],"versionCreatedAt":"2023-09-21 16:18:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3268862","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3268862","identity":"rs-3268862","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}