Cerebral Tuberculoma in a Patient With Pre-extensively Drug-Resistant Tuberculosis and AIDS: Diagnostic and Management Challenges.

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.