A70-08 A Ticking Time Bomb in the Third Ventricle: An Inoperable Deep-seated Brain Abscess in Disseminated Tuberculosis

Abstract Introduction Central nervous system (CNS) tuberculosis (TB) represents one of the most devastating manifestations of Mycobacterium tuberculosis infection, carrying high morbidity and mortality. While tuberculous meningitis is relatively common, the occurrence of the tuberculous brain abscess (TBA) is exceedingly rare, especially in non-HIV patients. Involvement of the ventricular system—particularly extension into the third ventricle—is an exceptional presentation. We report a case of disseminated tuberculosis with a rare combination of four neurological manifestations—abscess, meningitis, vasculitis, and radiculomyelitis. Case Presentation A 37-year-old woman presented with a one-month history of progressive headache, low-grade fever, weight loss, and acute urinary retention, without respiratory symptoms. Neurological examination revealed nuchal rigidity and a positive right-sided Chaddock’s sign. Cerebrospinal fluid (CSF) analysis demonstrated lymphocytic pleocytosis, profound hypoglycorrhachia (CSF/serum glucose ratio 0.10), and markedly elevated lactate (8.94 mmol/L). Although the acid-fast bacilli (AFB) smear was negative, Mycobacterium tuberculosis was detected by Xpert MTB/RIF assay on CSF. HIV test was negative. Chest computed tomography showed a diffuse miliary pattern, and brain MRI revealed a large, complex, ring-enhancing abscess arising from the right insular-temporal region with medial extension into the third ventricle. Based on these findings, disseminated tuberculosis with four neurological involvements—brain abscess, meningitis, vasculitis-related infarction, and radiculomyelitis—was diagnosed. Neurosurgical evaluation concluded that the deep intraventricular abscess was not amenable to surgical intervention due to its critical location and high operative risk. The patient received a 12-month anti-tuberculous regimen (2RHZE/10RHE) in combination with high-dose corticosteroids, resulting in marked clinical improvement within one week of treatment initiation. Discussion This case highlights a rare and complex form of CNS tuberculosis characterized by a deep-seated tuberculous brain abscess extending into the third ventricle. Such intraventricular involvement is associated with a grave prognosis due to its surgical inaccessibility and high risk of rupture or obstructive hydrocephalus. The presence of multiple concurrent neurological complications—abscess, meningitis, vasculitis, and radiculomyelitis—illustrates the multifocal and disseminated nature of miliary tuberculosis. Despite the unfavorable prognosis, the patient demonstrated substantial clinical recovery following aggressive medical management with the 12-month anti-tuberculous regimen and dexamethasone. Conclusion This case highlights an exceptional presentation of disseminated tuberculosis with four concurrent neurological manifestations in a non-HIV patient, highlighting the severe tuberculosis disease even in an immunocompetent host. We underscore the crucial evidence that aggressive medical therapy, including corticosteroids, can lead to favorable outcomes even in complex, surgically inoperable intraventricular CNS tuberculosis. This abstract is funded by: None