Cyclophosphamide treatment for unrelenting CNS vasculitis secondary to tuberculous meningitis

CNS arteritis develops in 30%–70% of TB meningitis cases.1,2 It often affects the basal arteries, resulting in ischemia and infarction of the diencephalon. In addition to anti-TB agents, treatment with steroids is used to modulate the inflammatory response. However, a paradoxical deterioration may follow.3,–,5 The most likely explanation is an enhanced delayed-type hypersensitivity response, leading to activation and accumulation of lymphocytes and macrophages at the site of bacillary deposition, or toxin production when the bacilli die.5 As with other types of vasculitis, steroids may not control such immunologic responses. ### Case report. A 19-year-old woman presented to the emergency department with fever, headache, ataxia, and altered mental status, with tachycardia and a temperature of 39°C. The neurologic examination showed papilledema, bilateral sixth nerve palsy, and nuchal rigidity. A chest X-ray revealed bilateral reticular infiltrates. The MRI showed meningeal enhancement, without parenchymal lesions (figure, A). The CSF examination revealed proteins of 189 mg/dL, glucose of 14 mg/dL, leukocytes of 47 cells/mm3, and adenosine deaminase enzyme of 10 …