Mkrtchyan Sahak
Department of Tuberculosis, Yerevan State Medical University After Mkhitar Heratsi, Yerevan, ARM.
Cureus. 2025 Aug 7;17(8):e89546. doi: 10.7759/cureus.89546. eCollection 2025 Aug.
Extrapulmonary tuberculosis (TB), particularly when it involves the central nervous system (CNS), remains a significant clinical challenge. Cerebral tuberculoma, though rare, can present with complex symptoms that overlap with other neurological conditions, making timely diagnosis difficult. The condition demands a multidisciplinary approach for accurate diagnosis and effective management, especially in patients with multiple comorbidities. This report describes a complex case of pre-extensively drug-resistant TB affecting both the lungs and CNS in a 54-year-old immunocompromised male with AIDS, chronic hepatitis B and C, COVID-19, and reactivated varicella. The patient presented with systemic symptoms and new-onset neurological deficits, including seizures and right-sided paresis. Brain MRI revealed a cerebral tuberculoma with surrounding edema. Sputum testing confirmed resistant to multiple first- and second-line agents. Treatment included a five-drug anti-tuberculosis regimen followed by initiation of antiretroviral therapy. The clinical course was complicated by immune reconstitution inflammatory syndrome, hepatic decompensation, and varicella reactivation. Despite profound immunosuppression and multisystem involvement, the patient achieved a favorable outcome through aggressive, multidisciplinary management. This case underscores the diagnostic complexity of CNS TB in patients with advanced HIV infection and multiple viral coinfections and highlights the critical role of early neuroimaging and coordinated care.
肺外结核病，尤其是累及中枢神经系统（CNS）时，仍然是一项重大的临床挑战。脑结核瘤虽然罕见，但可表现出与其他神经系统疾病重叠的复杂症状，导致难以及时诊断。这种情况需要多学科方法来进行准确诊断和有效管理，尤其是在患有多种合并症的患者中。本报告描述了一例复杂病例，一名54岁免疫功能低下的男性艾滋病患者，同时患有慢性乙型和丙型肝炎、COVID-19以及水痘复发，患有广泛耐药前结核病，累及肺部和中枢神经系统。患者出现全身症状和新发神经功能缺损，包括癫痫发作和右侧轻瘫。脑部MRI显示有一个伴有周围水肿的脑结核瘤。痰检证实对多种一线和二线药物耐药。治疗包括采用五种药物的抗结核方案，随后开始抗逆转录病毒治疗。临床过程因免疫重建炎症综合征、肝失代偿和水痘复发而复杂化。尽管存在严重免疫抑制和多系统受累，但通过积极的多学科管理，患者取得了良好的预后。该病例强调了晚期HIV感染和多种病毒合并感染患者中枢神经系统结核病的诊断复杂性，并突出了早期神经影像学检查和协调护理的关键作用。
