Contrasting Neurological Presentations of Tuberculosis: Based on Two Clinical Cases (Inflammatory Myelopathy Secondary to Tuberculous Spondylitis and TB-Associated Cerebral Vasculitis)

Background: Tuberculosis (TB) is a multisystem infectious disease with protean manifestations. Although pulmonary TB is most common, involvement of the central nervous system (CNS) is rare and potentially devastating. Neurological complications may occur due to direct infection, immune-mediated inflammation, or vascular involvement. Objective: To describe and analyze two uncommon neurological presentations of TB—non-compressive inflammatory myelopathy secondary to tuberculous spondylitis and TB-associated cerebral vasculitis—and to emphasize the importance of early recognition and treatment. Methods: Two patients with active TB presenting with acute neurological deficits were evaluated clinically and radiologically using MRI of the spine and brain. Laboratory investigations and chest imaging supported the diagnosis of TB. Both patients received standard anti-tuberculosis therapy (ATT) with adjunctive corticosteroids. Results: Case 1: A 50-year-old man with pulmonary TB developed acute flaccid paraplegia with sensory and autonomic involvement. MRI spine revealed L1 vertebral compression fracture consistent with TB spondylitis, without direct spinal cord compression. Neurological deficits were attributed to inflammatory spinal cord involvement. Significant neurological recovery followed ATT and corticosteroid therapy. Case 2: A 25-year-old man presented with seizures, altered sensorium, and right hemiparesis. MRI brain demonstrated multifocal ischemic infarcts. HRCT chest confirmed active pulmonary TB. TB endarteritis causing cerebral vasculitis was diagnosed. Combined ATT and corticosteroids led to marked clinical improvement. Conclusion: TB can cause rare but severe neurological complications through inflammatory and vascular mechanisms. Early diagnosis and combined anti-tubercular and anti-inflammatory therapy are crucial to prevent permanent neurological disability.