Symptoms and imaging findings of CNS tuberculosis can often be non-specific and a challenging diagnosis to make. Sarcoidosis is a multisystem granulomatous disorder that is characterized pathologically by the presence of noncaseating granulomas. Both CNS tuberculosis and neurosarcoidosis can have similar clinical presentations and imaging findings, making for a challenging diagnosis.

A 66 year-old female born in Tijuana, Mexico and immigrated to the United States when she was 17 with no significant medical history, presenting to the hospital with two year history of recurrent, episodic right arm numbness and weakness in addition to gradual development of headaches, vertigo and fevers. Initial MRI demonstrated an enhancing round mass at the left postcentral sulcus with linear extension of abnormal tissue along the postcentral sulcus contacting the dura. Additional imaging revealed no lymphadenopathy or pulmonary involvement. Lumbar puncture showed monocytic pleocytosis and elevated protein and patient was started on empiric antifungal coverage with amphotericin. Despite this, patient rapidly detiorated becoming encephalopathic and minimally responsive and subsequently developed acute communicating hydrocephalus and repeat MRI demonstrating progressive diffuse leptomeningeal enhancement. She was then taken to operating room for urgent external ventricular drainage and brain biopsy. Initial biopsy report revealed non-caseating granulomas further raising suspicion for neurosarcoidosis, however final path report growing acid fast bacilli confirming diagnosis of tuberculosis. Patient’s clinical status continued to decline, with family ultimately deciding to place patient on comfort care.

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The diagnosis of CNS tuberculosis can be a challenging diagnosis given the similar clinical manifestations, radiographic findings and overlap with neurosarcoidosis. This case highlights the importance of maintaining a high-index of suspicion for CNS tuberculosis when initial radiographic findings and biopsy results are suggestive of neurosarcoidosis. Given the opposing treatment for these two pathological processes, one must remain vigilant and early consideration given to empiric anti-TB treatment.