Disseminated Tuberculosis Presenting As Scrofuloderma and Tuberculous Meningitis With Ischemic Stroke in the Absence of a Pulmonary Disease

Extrapulmonary tuberculosis represents a significant proportion of tuberculosis cases, and scrofuloderma is an uncommon cutaneous manifestation caused by contiguous spread from underlying structures, such as lymph nodes, bone, or joints. Its association with central nervous system involvement, particularly tuberculous meningitis, is rare and carries a high risk of morbidity and mortality if not promptly recognized. We report the case of a 69-year-old man who initially presented with painful, indurated supraclavicular and anterior thoracic skin lesions that progressed to ulceration with seropurulent discharge, clinically consistent with scrofuloderma. This was followed by intermittent low-grade fever and subsequent subacute neurological deterioration, including altered mental status, headache, somnolence, ataxia, and disorientation. On admission, he was febrile and found to have severe hyponatremia, a frequent metabolic complication of tuberculous meningitis. Cerebrospinal fluid analysis revealed lymphocytic pleocytosis, markedly low glucose, and elevated protein and lactate, consistent with tuberculous meningitis. Brain magnetic resonance imaging demonstrated right insular leptomeningeal enhancement and a subacute ischemic infarction in the right corona radiata, suggestive of tuberculous vasculitis. Histopathological examination and GeneXpert testing (Cepheid; Sunnyvale, CA, USA) of a skin biopsy confirmed infection with Mycobacterium tuberculosis (MTB), establishing the diagnosis in the absence of pulmonary involvement. Antituberculous therapy and adjunctive corticosteroids were promptly initiated, with favorable clinical evolution and progressive neurological improvement. This case highlights scrofuloderma as a potential initial manifestation of disseminated tuberculosis and underscores the importance of maintaining a high index of suspicion for tuberculous meningitis in patients presenting with chronic ulcerative skin lesions and neurological deterioration, even without a pulmonary disease, as early diagnosis and treatment are critical to improving outcomes.