Chronic tuberculous meningitis presenting recurrent brainstem infarction without features of meningitis

: A 44-year-old woman with a history of transient right hemiparesis presented with personality change. One year later, she was admitted with ophthalmoparesis, dysarthria and regression phenomenon. MRI indicated acute infarction of the paramedian region of the midbrain and a nodular lesion in the interpeduncular fossa with contrast enhancement. Two years later, the patient was admitted with sudden onset of right hemiplegia. MRI showed acute infarction in the left side of the pons, diffuse brain atrophy, and abnormal contrast enhancement in the nodular lesion of interpeduncular fossa and leptomeninges of the ventral pons. MR angiography revealed that cerebral main tracts were intact, and cerebrospinal fluid analysis revealed mild pleocytosis and slightly elevated protein levels. Cervical lymph node biopsy demonstrated caseating granuloma with acid-fast bacilli. The patient was diagnosed with chronic tuberculous meningitis, even though tuberculous bacilli were not detected on polymerase chain reaction (PCR) or in culture. Antituberculous medication resulted in radiological resolution and neurological improvement. Although the patient had mild headache and pyrexia at the first admission, no signs of meningeal irritation were confirmed throughout the clinical course. We suspect that a paucity of tuberculous bacilli released from the tuberculous foci in the meninges to the subarachnoid space caused prolonged clinical course and lack of meningeal irritation signs.