Ischemic stroke in an adolescent as a sequelae of smear negative tuberculous meningitis

Introduction: Tuberculous meningitis (TBM) is fatal in approximately one-third of patients, and the sequelae of the disease in those who survive is challenging. It should be suspected in people residing in endemic areas with meningitis features. However, diagnosis of TBM is still a daunting challenge because it is usually based on clinical suspicion, cerebrospinal fluid findings, imaging techniques, and response to anti-tubercular therapy. Stroke is a rare complication of TBM, and it usually involves multiple areas supplied by perforating and cortical branches of the cerebral circulation rather than particular zones. Patient concerns: A 17-year-old male presented to the outpatient unit with fever and headache for 7 days, and altered sensorium for 1 day. The patient was unable to recognize his friends and family for 1 day and occasionally showed aggressive behavior. On examination, the patient had neck rigidity, positive Kernig's sign, and diminished breath sounds in the right lower zone of the right lung. Diagnosis: The patient was diagnosed with smear-negative TBM with pulmonary focus, which later developed into an ischemic stroke. Outcomes: The patient was treated with antitubercular therapy as per the national tuberculosis management protocol. Aspirin was added for stroke prevention and levetiracetam for seizure control. Conclusion: Stroke due to cerebral infarction can develop in a significant proportion of TBM patients, including adolescents. Hence, clinicians should have a high degree of clinical suspicion of TBM in endemic settings to prevent fatal complications such as stroke that may arise due to delayed diagnosis and treatment.