Neuromelanosis masquerading as tubercular bacterial meningitis

The coexistence of two diseases in a single child is rare, and one should be careful when diagnosing. Consideration of a second diagnosis becomes necessary, especially if it is treatable. Here, we present a toddler with paroxysmal events in the form of abnormal neck posturing, reduced vision, facial palsy and tremors involving all limbs following a febrile illness. On examination, the child had melanocytic naevi, altered consciousness, right lower facial nerve palsy, pyramidal signs, ataxia and dystonia. Neuroimaging showed communicating hydrocephalus and leptomeningeal enhancements, with cerebrospinal fluid (CSF) analysis showing lymphocyte-predominant leucocytosis; hence, the possibility of tuberculous meningitis was considered. The work-up for tuberculosis was unyielding. Anti-tubercular therapy (ATT) was started empirically. Repeat CSF analysis showed atypical pigmentary cells suggestive of melanocytes; hence, ATT was discontinued. In conclusion, the leptomeningeal enhancements and the hydrocephalus masqueraded as the picture of tuberculosis in neurocutaneous melanosis.