Tuberculous meningoencephalitis concurrent with autoimmune glial fibrillary acidic protein astrocytopathy: a case report

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Background: Tuberculous meningoencephalitis and autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy display similar clinical features, cerebrospinal fluid (CSF) profiles, and neuroimaging patterns, which contribute to a high rate of misdiagnosis. Co-existence of these two diseases is extremely rare, and the clinical characteristics of this overlap syndrome remain poorly understood. Case presentation: A 67-year-old male patient was admitted with symptoms of fever, cognitive slowing, and limb weakness. Brain magnetic resonance imaging (MRI) showed multiple parenchymal signal abnormalities and leptomeningeal enhancement, associated with markedly increased intracranial pressure. The CSF showed pleocytosis, increased protein, decreased glucose, and decreased chloride levels. Simultaneously, a positive result was obtained from GeneXpert MTB/RIF, which is a diagnostic tool for tuberculous meningoencephalitis. In addition, GFAP antibodies were positive in both serum and CSF. Thus, a diagnosis of tuberculous meningoencephalitis and GFAP astrocytopathy was made. The patient showed significant clinical improvement after receiving antitubercular drugs and corticosteroids. Repeat MRI after steroid discontinuation demonstrated an increase in abnormal enhancing lesions. The lesions improved after glucocorticoid reintroduction. Conclusion: Tuberculous meningoencephalitis and GFAP astrocytopathy represent a rare overlap syndrome, and these cases are potentially susceptible to therapeutic paradoxical reactions, which are visible on imaging studies. Therapy for these cases involves concomitant anti-infective and immunomodulatory therapy, with consideration for the timing of steroid tapering and discontinuation.

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