The Distracting Stroke in a Critically Ill Patient: Unveiling Hidden Miliary Tuberculosis

Abstract Stroke, one of the leading causes of mortality and morbidity, is commonly associated with risk factors like atherosclerosis, diabetes, and atrial fibrillation, but infections can also play a role in pathogenesis and can rarely manifest as primary presentation with stroke. A 55-year-old male with rheumatoid arthritis and dermatomyositis was found unresponsive, failing to respond even to painful stimuli and struggling with agonal breathing. He was urgently intubated. A computed tomography (CT) scan uncovered a devastating left middle cerebral artery infarct, leading to immediate treatment with aspirin, statins, and a nicardipine drip for blood pressure control. Further imaging revealed a catastrophic occlusion of the left internal carotid artery's cervical and intracranial segments. On examination, he showed spontaneous movement in the left limbs but complete flaccidity in the right side. An acute deep venous thrombosis was discovered in the right femoral, popliteal, and posterior tibial veins, though an echocardiogram ruled out interatrial communication. During treatment complications mounted as he developed ventilator-associated pneumonia, which, despite antibiotics, led to persistent fevers, tachycardia, and unstable blood pressure raising suspicion for paroxysmal sympathetic hyperactivity vs persistent infection making it difficult to wean off ventilatory support. Surprisingly, a CT chest scan revealed diffuse miliary pulmonary nodules, raising high suspicion for tuberculosis due to his recent travel history to Vietnam. Sputum tests confirmed the diagnosis of pulmonary tuberculosis (TB). He was isolated and treated with anti-tubercular therapy and intravenous steroids, he faced an unpredictable and severe course of illness, underscoring the complexity of his condition. Tuberculous meningitis has been documented to increase stroke risk, yet link between cryptogenic stroke and pulmonary TB remains less explored. A study revealed that overall risk of ischemic stroke is higher in TB patients, hazard ratio of 1.2 (95% CI, 1.10-1.36). Active pulmonary TB elevates inflammatory factors like C-reactive protein (CRP) and increases platelet activation, leading to a hyper-coagulable state. These not only raise the risk of ischemic stroke but also worsen prognosis, suggesting a link between active TB and stroke through inflammation and hyper-coagulability. Our case underscores the importance of considering infectious etiologies in stroke patients, particularly those with significant risk factors, as timely diagnosis and intervention could be pivotal in improving patient outcomes.