Tuberculosis Related Movement Disorders: A Systematic Scoping Review Highlighting Geographic Disparities, Phenotypic Patterns, Treatment Responses, and Knowledge Gaps in Global Reporting

Abstract

Background

Tuberculosis (TB) of the central nervous system (CNS) is a severe complication of TB, with movement disorders representing an under‐recognized yet impactful manifestation. Despite their clinical significance, knowledge gaps persist in epidemiology, pathophysiology, and management of TB‐related movement disorders (TBRMDs).

Objective

This scoping review synthesizes evidence on TBRMDs, aiming to characterize their spectrum, evaluate diagnostic approaches, and summarize management strategies and outcomes.

Methods

Following PRISMA‐ScR guidelines, a systematic search of PubMed, EMBASE, and Scopus (final search: December 31, 2024) identified studies of all designs and languages reporting movement disorders in CNS TB. Data extraction, quality assessment (Joanna Briggs Institute tools), and thematic synthesis were conducted.

Results

Of 36 included studies (91 cases), tremor (27.5%), chorea (26.4%), and dystonia (16.5%) were most prevalent. Tremor predominated in tuberculous meningitis (48.9%), while chorea was common in tuberculomas (42.3%). Lesion location correlated with phenomenology: basal ganglia lesions linked to chorea/dystonia, cerebellar involvement to ataxia. Pathogenesis included meningitis (54.9%), tuberculomas (32.9%), and vasculitis (8.8%). Treatment with anti‐tubercular therapy and corticosteroids resulted in complete resolution in 43.9% of cases, but 32.9% showed no improvement. Geographically, South America (61.8%) and Asia (19.7%) reported most cases, with a temporal surge post‐2000.

Conclusion

TBRMDs are heterogeneous in presentation, linked to lesion location and pathogenic mechanisms. Early recognition, multimodal management, and neuroimaging are critical. Significant variability in diagnostic and reporting standards highlights the need for consensus criteria and prospective studies, particularly in high‐burden regions. This review underscores the need of global collaborations to optimize clinical care and advance research in this neglected domain.

Tuberculosis (TB) remains a major global health concern, with an estimated 10.8 million people falling ill with TB worldwide in 2023 and 1.25 million deaths worldwide in 2023, ¹ signifying a 4.5% rise compared to 2021. ¹ Central nervous system (CNS) involvement occurs in approximately 1% of all TB cases, with tuberculous meningitis being the most severe form of extrapulmonary TB. ² While tuberculous meningitis and tuberculomas are well‐recognized manifestations of CNS TB, movement disorders represent an important yet under‐recognized complication. ³

Movement disorders associated with CNS TB encompass a spectrum of presentations, including hyperkinetic (chorea, tremor, myoclonus, dystonia), hypokinetic (parkinsonism), ataxia, and mixed syndromes. ⁴ These manifestations can occur at various stages: during acute infection, as paradoxical reactions during treatment, or as delayed complications. The pathophysiology involves multiple mechanisms: direct bacillary invasion, immune‐mediated inflammation, vasculitis‐related ischemia, and treatment‐related complications leading to injury of the basal ganglia, cerebellum, and other motor control regions. ⁵ Neuroimaging studies have demonstrated preferential involvement of the basal ganglia (particularly the striatum, substantia nigra), and cerebellum. ⁶

Early recognition and appropriate management of TB‐related movement disorders (TBRMDs) are crucial, as they significantly impact patients’ quality of life and functional status. Despite their clinical significance, current understanding of epidemiology, phenotypic characteristics, diagnostic approaches, and treatment strategies remains limited. This is particularly relevant in resource‐limited settings where both TB burden and diagnostic challenges are greatest. ⁷ A comprehensive review of the available literature is needed to synthesize the existing knowledge and identify areas for future research.

The primary objective of this scoping review is to comprehensively assess the current evidence on movement disorders associated with CNS TB. Specifically, we aim to: (1) characterize the spectrum and frequency of movement disorders in CNS TB, (2) evaluate diagnostic methods and their utility, and (3) summarize management strategies and their outcomes. By addressing these research questions, we seek to provide a robust, up‐to‐date summary of the existing literature, which can help clinical decision‐making and guide future investigations in this field.

Methods

Search Strategy and Information Sources

We conducted a comprehensive literature search using PubMed, EMBASE, and Scopus to identify relevant studies on movement disorders associated with tuberculosis of the nervous system. The final search was performed on December 31, 2024, without any date restrictions.

The search strategy was developed by combining keywords and Medical Subject Headings (MeSH) terms related to tuberculosis, nervous system involvement, and movement disorders. (Search terms are detailed in Data S1). The search strategy was first developed for PubMed and then adapted for other databases. Reference lists of included studies and relevant review articles were manually searched for additional eligible studies. In addition to the electronic database search, we manually searched the reference lists of the included studies and relevant review articles to identify any additional eligible studies. We also included studies published in languages other than English to ensure a comprehensive global representation.

Eligibility Criteria

Studies were included in the scoping review if they met the following criteria:

• Population: Patients of any age with central nervous system tuberculosis [CNS TB] or systemic TB, including but not limited to tuberculous meningitis, tuberculomas, and spinal tuberculosis.

• Exposure: Presence of movement disorders, such as tremor, chorea, dystonia, myoclonus, parkinsonism, ataxia, or others associated with tuberculosis of the nervous system or systemic tuberculosis.

• Comparator: Not applicable for this scoping review.

• Outcome: Clinical characteristics and movement disorders phenomenology, diagnostic methods, management strategies, and reported prognosis and outcomes for movement disorders related to tuberculosis of the nervous system or systemic tuberculosis.

• Study Design: All study designs, including case reports, case series, observational studies, and clinical trials, were eligible for inclusion.

We excluded studies that focused solely on movement disorders unrelated to tuberculosis of the nervous system or systemic tuberculosis, or drug‐induced movement disorders, or were conference abstracts, editorials, letters, or commentaries with inadequate details.

Study Selection

The study selection process was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses Extension for Scoping Reviews (PRISMA‐ScR) guidelines. ⁸ After removing duplicate records, three independent reviewers [SD, RY, DG] screened the titles and abstracts of the identified studies. Studies that met the inclusion criteria or had insufficient information to determine eligibility were selected for full‐text review. During the full‐text review, the same three reviewers independently assessed the eligibility of the studies. Any disagreements were resolved through discussion and consensus. The reasons for exclusion were documented. A PRISMA flow diagram illustrates the study selection process ⁸ (see Fig. 1).

FIG. 1.

Search methodology flowchart as per preferred reporting items for systematic reviews and meta‐analyses extension for scoping reviews (PRISMA‐ScR) guideline.

Data Extraction

Data extraction was performed by the three reviewers (SD, RY, DG) individually, using a standardized data extraction form (see Table S1). The following information was collected from the included studies:

• Study characteristics (author, year of publication, study design, country)

• Patient demographics (age, sex)

• Details of the tuberculosis of the nervous system or systemic tuberculosis (type, location, diagnostic methods)

• Characteristics of the associated movement disorders (type, clinical features, severity)

• Diagnostic approaches used to identify the movement disorders

• Management strategies and treatment outcomes

Quality Assessment

The methodological quality of the included studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklists, which are appropriate for various study designs. ⁹ Three reviewers independently evaluated the risk of bias and quality of the studies, and any disagreements were resolved through discussion to reach a consensus (see Table S2).

Data Synthesis and Analysis

Due to the heterogeneity of the included studies, we conducted a thematic synthesis of the findings. The extracted data was organized and analyzed to identify common themes, patterns, and key characteristics related to movement disorders associated with tuberculosis. The synthesis focused on the types of movement disorders reported, diagnostic approaches, management strategies, and treatment outcomes. We applied our proposed consensus definition, diagnostic criteria, and axis‐based classification framework on all the published cases of TBRMD to gain further insights and assess gaps in current knowledge of TBRMD ¹⁰ (see Table S3).

Results

Systematic Search Findings

Search Results

Our systematic search across multiple databases and additional sources identified a total of 279 studies potentially relevant to the review. Specifically, the searches yielded 272 records from electronic databases, including Scopus (n = 223), PubMed (n = 40), and Web of Science (n = 9). An additional seven records were identified through other sources, comprising citation searching (n = 3) and gray literature (n = 4). After removing duplicates (n = 97), which were identified using Covidence, 182 unique studies remained for initial screening. No studies were marked as ineligible by automation tools during this phase. Of the studies excluded after the initial screening, 96 were deemed irrelevant to the scope of the review. Upon further assessment, 86 studies were evaluated for eligibility based on their full texts. Of these, 50 studies were excluded further: 10 studies contained only abstracts with inadequate details, and 40 did not meet our inclusion criteria and exclusion criteria. Consequently, 28 English‐language studies were deemed eligible for inclusion in the review. In addition to the English‐language studies, 8 non‐English studies [3 Japanese, 2 Russian, 2 Spanish and 1 Turkish] met the inclusion criteria and were incorporated into the analysis. We utilized online translation software services to assess and extract data from non‐English articles. This approach allowed us to incorporate valuable data from diverse geographical regions while maintaining methodological rigor and consistency in our analysis. This resulted in a total of 36 studies included in the final review, encompassing 91 individual cases. Among these, the 28 English‐language studies contributed 76 cases, while the 8 non‐English studies provided an additional 15 cases. ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹ , ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ , ⁵⁴

Geographic Analysis

Geographic analysis demonstrated that the majority of cases were reported from South America (47 cases, 61.8%) and Asia (15 cases, 19.7%), with Ecuador contributing the highest number of cases (47 cases, 61.8%) due to two large prospective studies. Considering country‐wise data, the United States and India contributed the most reports (5 studies each, 17.9% each), followed by Ecuador (3 studies, 10.7%), Pakistan and Turkey (2 studies each, 7.1%). Single reports came from China, France, Hong Kong, Italy, Japan, Korea, Mexico, Morocco, Oman, Peru, Saudi Arabia, South Africa, and Suriname. ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹ , ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ The inclusion of non‐English studies highlighted additional cases from regions such as Japan (3 studies), Russia (2 studies), Spain (2 studies) and Argentina (2 study), further emphasizing the global nature of TBRMDs ³⁹ , ⁴⁰ , ⁴¹ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ , ⁵⁴ (see Fig. 2).

FIG. 2.

World map illustration [non‐political] depicting the geographic distribution of the cases of TB‐related movement disorders (TBRMD) published in medical literature.

Temporal Analysis

Temporal analysis revealed a significant increase in reported cases over the past four decades, with the highest number of cases reported in the 2000s (34 cases, 44.7%) and 2010s (30 cases, 39.5%). The median year of publication was 2011, with a notable surge in case reporting after 2000 (70 cases, 92.1%). The mean number of cases per study was 2.71 (range: 1–46), with prospective studies contributing the largest number of cases (46 cases, 60.5% of total).

Spectrum of TBRMDs

Our analysis revealed a diverse spectrum of TBRMDs, with tremor being the most prevalent (25 cases, 27.5%), followed by chorea (24 cases, 26.4%), dystonia (15 cases, 16.5%), and ataxia (7 cases, 7.7%). Less common manifestations included parkinsonism (5 cases, 5.5%), myoclonus (2 cases, 2.2%), and stereotypies (1 case, 1.1%). Notably, the distribution pattern varied by CNS TB type. In tuberculous meningitis (n = 42), tremor predominated (48.9%), followed by chorea (30.2%) and dystonia (18.6%). Conversely, in tuberculomas (n = 26), chorea was most frequent (42.3%), followed by dystonia (26.9%) and tremor (19.2%). Four patients presented with multiple movement disorders, highlighting the complex phenomenology of TBRMDs (see Table 1). Patient ages ranged from 6 months to 78 years, with substantial pediatric representation (see Fig. 2 and Table S1).

TABLE 1.

The spectrum of movement disorders by type of neuro‐tuberculosis (n = 91 ^a )

Tuberculous meningitis (n = 42)	Tuberculomas (n = 26) (%)	Total (including all TB cases) (n = 91) (%)	Total (including all TB cases) (n = 91) (%)	Details about resolution [In patients in which resolution occurred, when information available]
Tremor	21 (48.9)	5 (19.2)	26 (28.6)	11/26 patients showed resolution in 3–12 months of treatment
Dystonia b	8 (18.6)	7 (26.9)	15 (16.5)	7/15 patients showed resolution in 6–18 months
Chorea	13 (30.2)	11 (42.3)	24 (26.4)	7/24 patients showed resolution in 1–6 months
Myoclonus	1 (2.3)	1 (3.8)	2 (2.2)	Details not available
Parkinsonism	2 (4.7)	2 (7.6)	5 (5.5)	Details not available
Ataxia	2 (4.6)	3 (11.5)	7 (7.7)	4/ 7 patients showed resolution in a time frame of 3–24 months
Stereotypy	1 (2.3)	0	1 (1.1)	Resolved in 1 month

^a Four patients had both meningitis and tuberculoma; At least four patients had >1 movement disorder.

^b Among the cases of dystonia, we were able to classify the type in 8 of 15 cases. Focal dystonia was identified in 5 cases, while generalized dystonia was identified in 3 cases. The remaining 7 cases of dystonia were not specifically classified as focal or generalized in the source studies.

Affected Body Regions

Our analysis revealed that movement disorders associated with CNS TB predominantly affect the upper limbs, hemi‐body, and face. Tremor and dystonia commonly affect the upper limbs. ¹⁰ , ¹¹ Hemichorea and hemiballismus, often linked to basal ganglia or thalamic tuberculomas, significantly impact motor control. Facial involvement, including chorea, dystonia, and blepharospasm, is also notable. ¹⁴ , ¹⁸ This distribution highlights the diverse clinical presentations and underscores the need for comprehensive assessments to effectively manage TBRMDs.

Location of Tuberculoma Lesions in Relation to Movement Disorders

Our analysis highlighted a correlation between tuberculoma lesion locations and specific movement disorders. Basal ganglia lesions were frequently associated with chorea and dystonia. ¹² , ¹³ Thalamic lesions were linked to tremor and dystonia. ¹⁰ Cerebellar involvement was associated with ataxia. ¹¹ Brainstem lesions were implicated in ataxia and facial movement disorders. ³⁶ These findings underscore the importance of lesion location in understanding the pathophysiology of TBRMDs and guiding clinical management.

Pathogenesis

The pathogenesis of TBRMDs was attributed to various mechanisms: meningitis with or without hydrocephalus (50 cases, 54.9%), tuberculomas (30 cases, 32.9%), and vasculitis with infarction/hemorrhage (8 cases, 8.8%). Less common mechanisms included immune reconstitution inflammatory syndrome (IRIS) (6 cases, 6.6%) and hyponatremia due to syndrome of inappropriate antidiuretic hormone secretion (1 case, 1.1%). Nine cases (9.9%) demonstrated mixed pathogenesis, while one case had an unspecified mechanism (see Table 2).

TABLE 2.

Pathogenesis for tuberculosis‐related movement disorders

Pathogenesis d	Number of studies (n = 38)/Number of cases = 91
Tuberculoma	30
Meningitis ± hydrocephalus	50
Vasculitis with infarct/hemorrhage	8
Hyponatremia [SIADH]	1
IRIS b	6
Mixed c	10
Not mentioned a	6

All patients with vasculitis also had meningitis.

^a Chouksey and Pandey describe a patient with CNS TB who later on developed blepharospasm. [The exact mechanism was unknown, an old granuloma or infarct with gliosis was the suggested pathophysiology.].

^b IRIS: Immune reconstitution inflammatory syndrome. [IRIS] reported in a series of patients with meningitis, one patient developed tuberculoma after initial presentation as meningitis.

^c Some patients had both tuberculoma and meningitis.

^d Few cases report movement disorders related to drugs in patients with tuberculosis [eg isoniazid associated neuropathy in pulmonary tuberculosis, these are excluded as they do not represent TB related movement disorders].

Diagnosis

Diagnosis relied primarily on clinical features and neuroimaging findings. While all studies utilized neuroimaging (CT and/or MRI), only 12 cases (13.2%) reported confirmatory cerebrospinal fluid analysis and microbiological testing. Only two studies employed standardized diagnostic criteria for CNS tuberculosis. ²⁶ , ²⁷

Management and Treatment Outcomes

The cornerstone of management was anti‐tubercular therapy (ATT), frequently combined with corticosteroids. Symptomatic treatment varied by movement disorder phenomenology, including benzodiazepines, anticonvulsants, trihexyphenidyl, dopaminergic agents, dopamine receptor blockers, and botulinum toxin injections. Surgical interventions, including pallidotomy, decompression, and shunt placement, were employed in severe cases. ²⁵ , ²⁶ , ²⁷ , ³² , ³³

Treatment outcomes showed considerable variability: complete resolution in 40 cases (43.9%), no improvement or progression in 30 cases (32.9%), partial improvement with persistent symptoms in 10 cases (10.9%), and unclear outcomes in 11 cases (12.1%). Five patients (5.5%) developed IRIS‐related complications, including ataxia, seizures, and worsening sensorium. Movement disorders generally improved following shunt surgeries, and one case showed improvement after pallidotomy for persistent dystonia ²⁵ , ²⁶ (see Table 3). The timeframe for resolution varied significantly across studies and movement disorder types (Table 1). For tremor, resolution was reported in 11 of 26 patients, typically within 3–12 months of treatment initiation. Chorea showed resolution in 7 of 24 patients, with most cases improving within 1–6 months. Dystonia had a more variable course, with resolution occurring in 7 of 15 patients, typically within 6–18 months. Ataxia showed the most variability, with 4 of 7 cases resolving, but timeframes ranged from 3 months to over 2 years. Limited data was available for myoclonus and parkinsonism. Figure 3 provides a visual representation of resolution timelines across different movement disorder types, highlighting the variability in recovery patterns.

TABLE 3.

Treatment outcomes for tuberculosis‐related movement disorders

Outcome	Number of studies (n = 38/Number of cases = 91) a
Resolution of movement disorder	40
Persistent or progressive movement disorder with no improvement	30
Partial improvement of movement disorder but persistence	10
Unclear or not reported	11

^a One patient had improvement of stereotypy but persistence of Parkinsonism.

FIG. 3.

Bar graph showing minimum to maximum time of resolution of different movement disorders based on the available information. Chorea and Stereotypy show the fastest resolution (as low as 1 month). Dystonia has the longest minimum resolution time (6 months). Ataxia has the widest range of resolution time (3–24 months). Red line indicates 6‐month mark, orange line indicates 12‐month mark. Overall, movement disorders resolved within 1–24 months of treatment.

Quality Assessment

Using the Joanna Briggs Institute critical appraisal checklists, we found varying quality across studies. ⁹ Among case reports (n = 24), most effectively described patient demographics (88.9%) and clinical conditions (88.9%), but only 60.0% presented clear clinical timelines. While diagnostic testing was well‐documented (88.9%), intervention procedures were adequately described in only 56.0% of reports. The two prospective studies demonstrated strengths in exposure and outcome measurement but failed to address confounding factors or incomplete follow‐up strategies ¹⁶ , ²⁵ (see Table S2). This heterogeneity in methodological quality highlights the need for standardized reporting in future studies.

This comprehensive scoping review synthesizes the current evidence on TBRMDs, revealing both important insights and critical knowledge gaps in this challenging neurological manifestation of CNS TB. Our analysis demonstrates that TBRMDs represent a significant yet potentially under‐recognized complication of CNS TB, which may manifest at various stages after the infection and may represent a significant source of morbidity and functional impairment for affected patients. Notably, all age groups were represented (range 6 months to 78 years), with a substantial pediatric cohort (see Fig. 2 and Table S1).

Movement Disorder Phenomenology

A key finding of our review is the predominance of hyperkinetic movement disorders, particularly tremor and chorea, over hypokinetic syndromes. The differential pattern of movement disorders between tuberculous meningitis (predominantly tremor) and tuberculomas (predominantly chorea) suggests distinct pathophysiological mechanisms based on the type of CNS involvement. The affected body regions and the location of tuberculoma lesions provide critical insights into the pathophysiology of TBRMDs. Our analysis revealed that the upper limbs, hemi‐body, and face are most commonly affected, with specific lesion locations in the basal ganglia, thalamus, cerebellum, and brainstem correlating with distinct movement disorders. This correlation underscores the importance of lesion location in understanding the pathophysiology of TBRMDs and guiding targeted diagnostic work‐up and clinical management. The occurrence of multiple movement disorders emphasizes the complex interplay between TB‐related neuropathology and motor control systems.

Pathophysiology and Diagnosis

Direct effects of tuberculomas, meningeal inflammation, vascular complications, metabolic disturbances, and immune reconstitution contribute to the pathophysiology of TBRMDs suggesting that a single therapeutic approach may be insufficient. The involvement of the basal ganglia, particularly through vasculitis changes and inflammatory processes, appears to be a crucial mechanism in the development of TBRMDs. ⁶ , ⁷

Our review revealed significant variability in diagnostic approaches and reporting quality. The diagnostic approach to movement disorders in CNS TB primarily relied on clinical examination and neuroimaging findings, with CT and MRI being the most commonly used modalities. ⁶ , ⁷ CSF analysis and pathological and microbiological testing were also utilized in some studies to confirm the diagnosis of TB. The current reported diagnostic approach primarily relies on clinical examination and neuroimaging, with limited use of standardized movement disorder assessment tools. Modern neuroimaging techniques, particularly advanced MRI sequences, have enhanced our understanding of the structural and functional changes associated with TBRMDs. ⁶ , ⁷ Most of the reviewed studies did not provide detailed information on the specific diagnostic criteria or rating scales used to assess and characterize movement disorders. We applied our recently proposed definition, diagnostic criteria, and axis‐based classification framework to all the published cases in this review (see Table S3). ¹⁰ We found a wide variability in the quality and depth of movement disorder characterization. The diagnostic certainty of tuberculosis ranged from definite to possible, with only a subset of cases having microbiological confirmation. This finding underscores the critical need for standardized diagnostic approaches and reporting standards in future studies. The proposed axis‐based classification system and diagnostic criteria framework for infection‐related movement disorders may significantly enhance the quality and comparability of future studies by emphasizing the importance of detailed clinical descriptions, temporal relationships, and diagnostic certainty. ¹⁰ Additionally, the absence of video documentation in most reports further complicated the assessment of movement disorder phenomenology. The paucity of video documentation, particularly in recent cases where technology readily permits this, represents a missed opportunity for enhancing phenomenological understanding and teaching.

Geographic and Temporal Distribution

The geographic distribution of reported cases in our review reveals important disparities in the recognition and reporting of TBRMDs. There is a notable concentration of reports from the United States, India, and Ecuador. Despite the high burden of TB in Africa and Southeast Asia, these regions are underrepresented in the literature on TBRMD. This disparity likely reflects limitations in access to neurological expertise, diagnostic resources, and research infrastructure rather than a true geographical variation in disease occurrence. The significant contribution from Ecuador, through two prospective studies, underscores the importance of systematic research efforts in enhancing our understanding of TBRMD. ¹⁶ , ²⁵ In 2023, according to WHO estimates 10.8 million people worldwide were newly infected with TB. The number of TBRMD is not specified in the WHO report. Temporal analysis revealed a significant increase in reported cases over the past four decades, with the highest number of cases reported in the 2000s and 2010s.

Treatment Outcomes and Management

Treatment outcomes considerably varied, with complete resolution in nearly half of the cases (43.9%) but persistent or progressive symptoms in others. This variability in outcomes may be attributed to factors such as the timing of diagnosis, severity of CNS involvement, and effectiveness of treatment. It also highlights the challenging nature of TBRMD management which requires a comprehensive approach to both diagnosis and treatment, and addressing underlying pathophysiological mechanisms. ³⁹ , ⁴⁰ , ⁴¹ The prognostic value of specific movement disorder types or patterns in CNS TB has not been evaluated. Our review suggests that the development of movement disorders may be a marker of increased disease severity and poorer prognosis in CNS TB.

Anti‐tubercular therapy (ATT) remains the cornerstone of treatment Adjunctive corticosteroids, possibly combined with anti‐inflammatory drugs, and aspirin for stroke prevention, and may play a crucial role in reducing inflammation and potentially preventing movement disorders. ⁴ The optimal duration of steroid therapy and the role of other immunomodulatory treatments in such cases requires further investigation. The development of paradoxical reactions through immune reconstitution inflammatory syndrome (IRIS) adds another layer of complexity to management decisions. ⁴² , ⁴³

The frequent need for additional symptomatic management with medications like benzodiazepines, anticonvulsants, and dopaminergic agents underscores the complexity of these cases. The need for surgical interventions (shunt placements or pallidotomy) in refractory cases highlights the potential severity and persistence of TBRMDs, and underscores the importance of early recognition and aggressive management. ²⁶ , ²⁷

This variability in management approaches and outcomes points to a critical gap in standardized treatment protocols, emphasizing the need for evidence‐based guidelines.

Limitations

Our review has some limitations. First, the geographic distribution of reported cases is skewed towards regions with better healthcare infrastructure and research capabilities, potentially underestimating the true global burden of TBRMDs. Second, the heterogeneity in study design, diagnostic approaches, and outcome reporting limits the strength of evidence available to guide clinical practice. In particular, the retrospective nature of most studies and variable follow‐up periods limits our ability to characterize the natural history of TBRMDs and identify factors associated with poor outcomes. Third, the lack of standardized terminology and assessment tools may have led to both under‐recognition and misclassification of movement disorders in the context of CNS tuberculosis. Fourth, we identified insufficient documentation of HIV status across studies, despite the well‐established neurological complications of HIV‐TB co‐infection. Given that HIV infection can significantly modify the presentation and course of CNS TB, this knowledge gap hampers our understanding of potential interactions between these conditions in the context of movement disorders. ⁴⁴

To address these limitations, we propose several key research priorities. The development and implementation of standardized diagnostic criteria, assessment, and reporting tools for TBRMDs is essential for accurate phenotyping and outcome measurement. ¹⁰ , ³⁹ , ⁴⁵ The establishment of multicenter registries, particularly in high‐burden TB regions, would facilitate the collection of comprehensive longitudinal data and enable better characterization of clinical trajectories. Such registries should incorporate systematic documentation of HIV status, immunological parameters, and detailed treatment protocols. Prospective studies investigating early recognition and intervention strategies are crucial, as highlighted by recent evidence suggesting that prompt immunomodulation may improve outcomes in certain forms of CNS TB. ⁴⁶ The identification of reliable biomarkers for prediction and monitoring of TBRMDs represents another critical research avenue. ⁴⁷ Furthermore, investigation of host genetic factors and immune responses could provide insights into individual susceptibility and guide personalized therapeutic approaches. ⁴⁴ , ⁴⁶

Conclusion

Our findings have important implications for clinical practice. Movement disorders may manifest at any stage of CNS tuberculosis, necessitating vigilant monitoring throughout the disease course. A multimodal management approach, incorporating anti‐tuberculosis therapy, immunomodulation, and targeted symptomatic treatment, appears most effective based on current available evidence. ³⁹ Regular assessment for paradoxical reactions and immune reconstitution inflammatory syndrome (IRIS) is essential, particularly in HIV‐positive patients. ⁴² , ⁴³

This scoping review also highlights substantial gaps in our understanding of TBRMDs while providing a framework for future research directions. The complexity of these disorders demands a collaborative approach between neurologists, infectious disease specialists, and researchers. Implementation of standardized assessment protocols, coupled with systematic prospective studies, will be crucial in advancing our knowledge and improving patient outcomes. The establishment of international research networks focused on TBRMDs could accelerate progress in this important yet understudied area of neurological complications in tuberculosis.

Author Roles

(1) Research Project: A. Conception, B. Organization, C. Execution; (2) Statistical Analysis: A. Design, B. Execution, C. Review Critique; (3) Manuscript preparation: A. Writing First Draft, B. Review and Critique.

S.D.: 1A, 1B, 1C, 2A, 2B, 2C, 3A, 3B

R.Y.: 1B, 1C, 2A, 2B, 2C, 3B

D.G.: 1C, 2A, 2B, 2C, 3B

S.S.: 1B, 1C, 2A, 2B, 2C, 3B

P.K.P.: 1B, 2A, 2C, 3B

Disclosures

Ethical Compliance Statement: The authors confirm that the approval of an institutional review board/ patient consent was not required for this work. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines.

Funding Sources and Conflicts of Interest: No specific funding was received for this work. The authors declare that there are no conflicts of interest relevant to this work.

Financial Disclosures for the Previous 12 Months: The authors declare that there are no additional disclosures to report.

Supporting information

Data S1. Search methodology.

TABLE S1. Details of individual cases/studies on TB‐related movement disorders (TBRMDs) synthesized in this review.

TABLE S2. Quality assessment of case reports and case series.

TABLE S3. Application of the proposed classification and definition of IRMD to assess published cases of TB‐related movement disorders (TBRMDs).

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.