INFECTION BY MYCOBACTERIUM TUBERCULOSIS WITH MENINGEAL MANIFESTATION AND RAPID DISEASE PROGRESSION: A CASE REPORT IN A YOUNG, IMMUNOCOMPETENT PATIENT

A 25-year-old woman, previously healthy and vaccinated with BCG, developed refractory headache and paroxysmal episodes of loss of consciousness with stereotyped movements. There was a history of occupational exposure to a coworker with respiratory symptoms approximately one month earlier. At that time, with the aid of chest computed tomography (CT) and cerebrospinal fluid (CSF) collection with molecular rapid test for tuberculosis (TRM-TB), she was diagnosed with pulmonary and meningeal tuberculosis. Possible causes of immunosuppression and Mycobacterium tuberculosis resistant to the standard regimen were ruled out. After 45 days of outpatient treatment, she developed neuropsychiatric manifestations (childish behavior, aggressiveness, apathy, and mental confusion) and reduced visual acuity. Neurological examination revealed signs of intracranial hypertension (bilateral sixth cranial nerve palsy) and meningeal irritation (positive Kernig and Brudzinski signs), as well as bilateral amaurosis. Cranial CT showed intense pachymeningeal enhancement at the skull base, accompanied by collections in the crural and interpeduncular cisterns, causing obstructive hydrocephalus and transependymal edema. Emergency external ventricular drainage (EVD) was indicated, associated with intravenous corticosteroid therapy to reduce the inflammatory process. There was substantial clinical and radiological improvement, allowing EVD removal. However, due to recurrent headache and hydrocephalus relapse, the patient underwent ventriculoperitoneal shunt placement (VPS). Despite this, her condition progressed unsatisfactorily, and she was referred for follow-up with the palliative care team. Extrapulmonary tuberculosis manifestations in young, immunocompetent adults previously vaccinated with BCG and not using immunosuppressive drugs are uncommon. The absence of prior respiratory symptoms and the rapid neurological progression confer relevance to this case, highlighting the importance of clinical suspicion and early diagnosis of tuberculous meningitis even in individuals without classic risk factors.