Case Report
Revealing Primary CNS Vasculitis in the Shadow of Tuberculosis
Mukherjee A*, Kumari P, Rautiya V, Vyshnavi G, Sangharsh, Mahima M, Wasnik P, Pranita and Shukriya S
Department of Medicine, All India Institute of Medical Sciences (AIIMS), Raipur, Chhattisgarh, India
*Corresponding author:Avinash Mukherjee, Department of Medicine, All India Institute of Medical Sciences (AIIMS), Raipur, Chhattisgarh, India, Email Id: avinashmukherjee91@gmail.com
Article Information:Submission: 10/07/2025; Accepted: 29/07/2025; Published: 31/07/2025
Copyright: © 2025 Mukherjee A, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Introduction:Primary angiitis of the central nervous system (PACNS) is a rare and often under- recognized form of vasculitis confined to the CNS. It typically presents with non- specific neurological symptoms, making it difficult to distinguish from infections, malignancies, and demyelinating disorders, especially in regions endemic for tuberculosis.
Aim:To highlight the diagnostic challenges of PACNS in young individuals and emphasize the importance of a thorough differential workup in cases presenting with recurrent or treatment-resistant neurological symptoms.
Case:A 24-year-old previously healthy male presented with chronic holocranial headache and episodic neurological symptoms including slurred speech and altered sensorium. He was initially diagnosed and treated as a case of tubercular meningitis. However, recurrence of symptoms despite appropriate therapy prompted re-evaluation. MRI findings showed multiple micro-bleeds and perivascular enhancement with MR angiography showing “skipped” or “segmental” pattern of vessel involvement seen — a classical radiological hallmark of PACNS. CSF analysis and serologic workup ruled out infectious and systemic autoimmune etiologies. Based on imaging and exclusion of other causes, a diagnosis of PACNS was made.
Results:The patient was treated with intravenous methylprednisolone followed by oral steroids, low-dose aspirin, and rituximab. He showed significant clinical improvement with no recurrence on follow-up. The case underscores the value of revisiting diagnoses when initial treatment fails, especially in atypical presentations.
Aim:To highlight the diagnostic challenges of PACNS in young individuals and emphasize the importance of a thorough differential workup in cases presenting with recurrent or treatment-resistant neurological symptoms.
Case:A 24-year-old previously healthy male presented with chronic holocranial headache and episodic neurological symptoms including slurred speech and altered sensorium. He was initially diagnosed and treated as a case of tubercular meningitis. However, recurrence of symptoms despite appropriate therapy prompted re-evaluation. MRI findings showed multiple micro-bleeds and perivascular enhancement with MR angiography showing “skipped” or “segmental” pattern of vessel involvement seen — a classical radiological hallmark of PACNS. CSF analysis and serologic workup ruled out infectious and systemic autoimmune etiologies. Based on imaging and exclusion of other causes, a diagnosis of PACNS was made.
Results:The patient was treated with intravenous methylprednisolone followed by oral steroids, low-dose aspirin, and rituximab. He showed significant clinical improvement with no recurrence on follow-up. The case underscores the value of revisiting diagnoses when initial treatment fails, especially in atypical presentations.
Keywords:PACNS, Young Adult; Refractory Headache; Microbleeds; Rituximab; Tubercular meningitis mimics