Miliary tuberculosis complicated by tuberculous vasculitis and ischemic stroke in a 16-year-old female patient: a case report

Abstract

Background

Miliary tuberculosis is a disseminated form of the disease that can lead to serious complications. This case report describes the clinical presentation, management, and outcomes of a 16-year-old female patient who developed severe neurological deficits and systemic symptoms.

Case presentation

A 16-year-old female from Ethiopia presented with a 1-month history of productive cough with whitish sputum, low-grade fever, night sweats, significant weight loss, and episodes of vomiting. She later developed right-sided hemiplegia and Broca’s aphasia. She was managed with first-line antituberculosis drugs (rifampicin/isoniazid/pyrazinamide/ethambutol), prednisolone, pyridoxine, nutritional therapy with Plumpy Nut, and bedside physiotherapy. Upon discharge, the patient showed significant improvement in her appetite and neurological function, including the ability to produce sounds and call names. Follow-up evaluation 2 months later indicated further progress, with weight gain, improved mobility, and fluent speech. Muscle strength in her right upper and lower extremities improved to a grade of 3/5, enabling her to lift and move the affected limbs against gravity, although not against resistance. These findings indicate substantial recovery of motor function and overall clinical status.

Conclusion

This case highlights the challenges of managing miliary tuberculosis with complications such as vasculitis and ischemic stroke. Early diagnosis and a comprehensive treatment approach, including antituberculosis therapy and rehabilitation, led to significant improvement. It underscores the need for strengthened healthcare systems and timely interventions to improve outcomes in complex tuberculosis cases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13256-026-05842-1.

Introduction

Tuberculosis (TB) remains one of the leading infectious diseases worldwide, causing high morbidity and mortality, particularly in resource-limited settings [1]. According to the World Health Organization (WHO), approximately 10.8 million people developed TB globally in 2023, with nearly 1.25 million deaths [2]. Ethiopia is no more among high multidrug-resistant (MDR)-TB burden country, though it remains among high TB burden countries [3]. In 2022, the National TB Program of Ethiopia reported a total of 156,000 TB cases, with an estimated incidence rate of 126 cases per 100,000 population [4]. While pulmonary TB is the most common form, extrapulmonary TB can involve almost any organ system, presenting as conditions such as miliary TB, tuberculous meningitis, and tuberculous vasculitis, which can lead to serious neurological complications [5].

Miliary TB is a disseminated form of TB that results from hematogenous spread of Mycobacterium tuberculosis [6]. It is characterized by a diffuse reticulonodular pattern on chest imaging and involvement of multiple organs, including the lungs, liver, spleen, and central nervous system (CNS) [7]. TB vasculitis, though rare, is one of the most serious complications, involving inflammation and necrosis of the cerebral vasculature, leading to ischemic or hemorrhagic strokes [8]. Neurological involvement in TB is an indicator of poor prognosis, particularly in young patients, and can present with various symptoms, including focal neurological deficits, cognitive impairment, or seizures [9, 10].

While ischemic strokes resulting from tuberculous vasculitis are relatively rare, they can affect both adults and children [11]. Diagnosing strokes in younger patients is particularly challenging owing to a broad differential diagnosis, including autoimmune vasculitis and infectious conditions [12]. In resource-limited settings such as Ethiopia, insufficient access to early diagnostic tools and healthcare resources often delays detection and treatment, leading to complications such as tuberculous vasculitis, which can result in ischemic strokes and other neurological deficits [13–15]. This case report examines the presentation, diagnostic process, and management approach for a 16-year-old female patient from Ethiopia with miliary TB, whose condition was complicated by an ischemic stroke likely secondary to tuberculous vasculitis, underscoring the importance of recognizing TB’s potential CNS involvement in young patients.

Case presentation

A 16-year-old female from Ethiopia presented with a 1-month history of productive cough with whitish sputum, low-grade fever, night sweats, significant but unquantified weight loss, and episodes of vomiting. She has no other medical conditions and no family history of relevant medical conditions. She has no history of smoking or alcohol consumption or any illicit drug use. She initially sought care at a local hospital, where she was treated with intravenous broad-spectrum antibiotics (ceftriaxone and vancomycin) and anti-TB medications for presumptive diagnoses of severe community-acquired pneumonia and pulmonary TB, respectively. However, after a week of treatment, her condition deteriorated, and she developed a sudden-onset of right-sided body weakness and impaired communication, prompting her referral to Jimma Medical Center (JMC).

On arrival at JMC, she appeared chronically ill. Her vital signs were notable for a blood pressure of 110/60 mmHg on the right arm and 105/65 mmHg on the left arm, a pulse rate of 112 beats per minute that was regular and full in volume, respiratory rate of 22 breaths per minute, temperature of 36.2 °C, and peripheral oxygen saturation of 95% on room air. She weighed 26 kg, with a height of 145 cm, resulting in a body mass index (BMI) of 13 kg/m², and had a mid-upper arm circumference (MUAC) of 15 cm, indicating severe malnutrition.

Examination of her head, eyes, ears, nose, and throat (HEENT) revealed no abnormalities except for conjunctival pallor. Chest, cardiovascular, and abdominal examinations were also unremarkable. Her integumentary and musculoskeletal examination revealed no edema, rash, or purpura, though mild palmar pallor was present.

On neurological examination, she was conscious with a Glasgow Coma Scale score of 10/15 (with aphasia). She exhibited impaired language fluency with intact comprehension, indicating Broca’s aphasia. All cranial nerves were intact, and her pupils were mid-sized and reactive bilaterally. On motor examination, no spontaneous or induced fasciculations were observed, and muscle bulk was symmetrical bilaterally. However, she had severe weakness on the right side, with muscle power graded at 0/5 in the right upper and lower extremities, while the left side had full strength (5/5). Muscle tone was normal in all extremities. Deep tendon reflexes were graded +2 on the knee, ankle, biceps, and triceps bilaterally, and her plantar reflex was equivocal. Sensory examination showed no deficits, with intact sensation to pain, touch, and position bilaterally.

Following the initial clinical assessment, further investigations were conducted. A chest X-ray revealed a miliary pattern consistent with disseminated TB (Fig. 1). Brain computed tomography (CT) demonstrated a hypodensity with loss of the insular ribbon sign in the left middle cerebral artery territory, indicative of acute ischemic infarction (Fig. 2). Sputum GeneXpert was positive for Mycobacterium tuberculosis, confirming the diagnosis of pulmonary TB. Echocardiography revealed normal cardiac structure and function. Complete blood count, blood chemistry, and urine tests were largely within normal limits, except for mild anemia, with a hemoglobin level of 10.1 g/dL. The diagnosis of miliary tuberculosis complicated by tuberculous vasculitis, and ischemic stroke was suspected on the basis of clinical findings and laboratory findings. However, there were other possibilities that were considered as described below.

Fig. 1.

Chest X-ray showing a miliary pattern indicative of disseminated tuberculosis

Fig. 2.

Non-contrast brain computed tomography scan. The scan reveals a significant area of hypodensity in the left middle cerebral artery territory. The smaller green arrows indicate the loss of the “insular ribbon sign,” while the larger green arrows highlight the extent of the acute ischemic infarction, consistent with a major territory stroke

In the differential diagnosis, several conditions were carefully evaluated. Giant cell arteritis was initially considered owing to the presence of B symptoms such as low-grade intermittent fever, weight loss, anorexia, and night sweating, along with body weakness and aphasia. However, the patient’s age (16 years) and the absence of hallmark symptoms such as temporal headache, jaw claudication, or vision loss, as well as the infarction being in the MCA territory, made this diagnosis unlikely [16].

Primary CNS vasculitis was also considered because of the B symptoms, body weakness, aphasia, and the young age of the patient. However, the presence of miliary tuberculosis and the temporal association with TB treatment (neurological symptoms emerged shortly after starting anti-TB therapy) pointed away from this diagnosis [17, 18]. Kawasaki disease was ruled out owing to the patient’s age (typically affecting children under 5 years) and the presentation of focal neurological deficits, which is not typical of Kawasaki disease [19].

Systemic lupus erythematosus was considered given the presence of B symptoms and neurological deficits in a young patient; however, the patient did not meet the 2012 systemic lupus international collaborating clinics (SLICC) criteria, and antinuclear antibody (ANA) was negative, which is an entry criterion for the 2019 European Alliance of Associations for Rheumatology (EULAR)/American College of Rheumatology (ACR) criteria [20, 21]. Takayasu arteritis was also considered owing to the presence of B symptoms and body weakness with aphasia at a young age. However, the absence of peripheral pulse discrepancies, bruits, or limb claudication and normal blood pressure readings between the arms made this diagnosis unlikely [22].

Cardioembolic stroke was considered owing to the young age and neurological symptoms of body weakness and aphasia. However, the absence of a history of cardiac illness, orthopnea, paroxysmal nocturnal dyspnea, body swelling, and a normal echocardiogram, as well as normal electrocardiogram (ECG) exclude this diagnosis. Tuberculoma was considered because the patient exhibited signs and symptoms consistent with TB, including right-sided body weakness and Broca’s aphasia, with a chest X-ray showing a miliary pattern and positive sputum GeneXpert for Mycobacterium tuberculosis. However, the brain CT did not show any mass lesion, making tuberculoma unlikely.

The diagnosis of tuberculous vasculitis was strongly supported by the presence of TB-related symptoms, neurological abnormalities consistent with stroke, characteristic abnormalities on chest X-ray abnormalities, and the confirmed detection of Mycobacterium tuberculosis in the sputum [23, 24]. The concurrent diagnoses of adult-onset malnutrition and mild anemia were indicative of nutritional deficiencies, likely secondary to the chronic inflammatory state associated with tuberculosis. This aligns with the well-documented impact of prolonged inflammation on metabolic processes, appetite regulation, and nutrient absorption, commonly observed in patients with tuberculosis [25, 26].

The management included a multidisciplinary approach. This included a four-drug regimen of antituberculous therapy consisting of rifampicin/isoniazid/pyrazinamide/ethambutol to address the underlying tuberculosis infection. Prednisolone was administered to reduce inflammation associated with the suspected tuberculous vasculitis. Nutritional support with Plumpy Nut was provided to address malnutrition. Bedside, physiotherapy was implemented to improve motor function and speech. Supportive care, including pyridoxine to prevent neurological side effects of isoniazid, was also provided.

At discharge, the patient showed significant improvement; her appetite had increased, and she had begun producing sounds and calling names. Her motor strength progressed, with right upper extremity strength recorded at 0/5 and right lower extremity strength at 3/5, while both the left upper and lower extremities remained at 5/5. She was discharged after 14 days of hospital stay with the anti-TB drugs, prednisolone at 25 mg orally daily (with gradual tapering), pyridoxine at 25 mg orally daily, and ongoing nutritional support with Plumpy Nut, along with advice for continued physiotherapy. A follow-up appointment was scheduled for 2 weeks post discharge. At 3 weeks later, the patient reported a good appetite, weight gain, the ability to walk unsupported to the toilet and around her home, fluent communication, and mild improvement in her right upper extremity strength. Upon further evaluation 2 months later, the patient demonstrated continued progress, including the ability to lift both the right upper and lower extremities with muscle strength graded at 3/5. Regarding tuberculosis treatment, the patient adhered to the prescribed four-drug regimen, and there were no reported adverse events.

Discussion

This case highlights the complexities and challenges associated with diagnosing and managing miliary TB in a young patient, particularly in resource-limited settings such as Ethiopia. The patient, a 16-year-old female, presented with classic symptoms of TB, including a productive cough, fever, night sweats, and significant weight loss. Despite initial treatment for severe community-acquired pneumonia and pulmonary TB, her condition deteriorated, leading to neurological deficits characterized by right-sided hemiplegia and Broca’s aphasia. This progression underscores the critical importance of early and accurate diagnosis of TB and anticipation of its potential serious complications.

Miliary TB is known for its potential to disseminate throughout the body, affecting multiple organ systems and leading to severe complications such as tuberculous vasculitis, which can result in ischemic strokes [15]. The patient’s imaging findings—specifically the hypodensity in the left middle cerebral artery territory—are consistent with an acute ischemic stroke secondary to this vasculitis. One of the key differential diagnoses in such cases is tuberculous meningitis [27]. However, the absence of elevated protein or low glucose levels in the cerebrospinal fluid (CSF) makes such a diagnosis less likely. This case illustrates the necessity for comprehensive diagnostic approaches that include imaging studies and CSF analysis to differentiate between various forms of TB-related complications.

The management plan employed for this patient included anti-TB therapy alongside corticosteroids, nutritional support, and physiotherapy. Although the effectiveness of corticosteroids in reducing strokes has not been established, its administration in conjunction with antitubercular therapy is believed to decrease mortality and morbidity, especially in cases where TB involves the nervous system [11]. By mitigating inflammatory responses, corticosteroids may help alleviate neurological deficits associated with the disease [28]. The positive response to treatment observed at discharge—marked by improved motor function and communication abilities—demonstrates the potential for recovery when appropriate interventions are implemented timely. Clinical studies have shown that early treatment correlates with better functional recovery, emphasizing the importance of prompt medical intervention in mitigating the effects of neurological complications associated with TB [29–31].

However, this case also highlights systemic issues within healthcare delivery in resource-limited settings. Delays in diagnosis and treatment can lead to significant morbidity and mortality associated with miliary TB. The lack of access to rapid diagnostic tools and specialized care often results in advanced disease presentations by the time patients receive appropriate medical attention. This is evidenced by a study that reported a median diagnostic delay of 6.5 months for disseminated TB, leading to advanced disease presentations and poorer patient outcomes [32].

Moreover, nutritional support plays a vital role in the management of patients with miliary TB, especially given the severe malnutrition observed in this case (BMI of 13 kg/m²). Malnutrition not only complicates recovery but also weakens the immune response, making patients more susceptible to infections [33]. Research has shown that malnourished patients with TB experience delayed recovery and higher mortality rates compared with well-nourished individuals, emphasizing the necessity of addressing nutritional deficiencies to enhance treatment outcomes [33, 34].

Strength and limitation

This case report highlights a unique presentation of tuberculous vasculitis leading to ischemic stroke in a young patient with miliary tuberculosis, offering valuable insights into rare TB-related complications. The case underscores the importance of a multidisciplinary approach, involving the combination of anti-TB therapy, nutritional support, and physiotherapy, which led to a positive clinical outcome. It is particularly relevant for resource-limited settings, such as rural Ethiopia, where access to advanced diagnostic tools may be restricted, and clinical judgment plays a pivotal role in patient management. However, there are notable limitations. The diagnosis of tuberculous vasculitis was not confirmed through advanced diagnostic methods, such as tissue biopsy, angiography, or serology (for example, antineutrophil cytoplasmic antibody (ANCA)), which would have provided definitive confirmation. Additionally, as a case report, the findings may not be generalizable to broader populations owing to the unique nature of the patient’s presentation. The relatively short follow-up period also limits the ability to assess long-term outcomes or potential recurrences, thus warranting further research and follow-up to confirm the sustained benefits of the treatment approach.

Conclusion

This case report presents a complex clinical scenario of a young patient diagnosed with miliary TB, complicated by tuberculous vasculitis and ischemic stroke. The presentation underscores the importance of early diagnosis and timely intervention, particularly in resource-limited settings such as Ethiopia, where access to rapid diagnostic tools and specialized care is often inadequate. Ultimately, this case reinforces the necessity of a comprehensive and multidisciplinary approach to optimizing outcomes for patients affected by complex TB-related conditions.

Abbreviations

TB

Tuberculosis

WHO

World Health Organization

CNS

Central Nervous System

JMC

Jimma Medical Center

BMI

Body Mass Index

MUAC

Mid-upper arm circumference

HEENT

Head, eyes, ears, nose, and throat

MCA

Middle cerebral artery

CT

Computed tomography

ECG

Electrocardiogram

CSF

Cerebrospinal fluid

SLICC

Systemic lupus international collaborating clinics

ANA

Antinuclear antibody

EULAR

European Alliance of Associations for Rheumatology

ACR

American College of Rheumatology

MRI

Magnetic resonance imaging

Author contributions

EKG designed and conceptualized the study. SKA and EGA wrote the original draft. SKA was involved in data curation. EKG provided supervision for the overall activities. All authors accepted responsibility for all aspects of the research, including writing, reviewing, and editing, and approved the final version of the manuscript.

Funding

This research received no specific grant from any funding agency in the public, commercial, or nonprofit sectors.

Data availability

The data supporting the findings of this case are included within the manuscript, and additional data are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Written informed consent was obtained from the patient’s legal guardian for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Conflict of interest

The authors report no conflicts of interest in this work.