Radiographic resolution of presumed cerebellar tuberculoma during extended BPaLM-based therapy for disseminated multidrug-resistant tuberculosis

Central nervous system (CNS) involvement in multidrug-resistant tuberculosis (MDR-TB) is associated with high morbidity, and evidence guiding the use of standardized all-oral regimens in intracranial disease is limited. We describe radiographic evolution of a presumed cerebellar tuberculoma during BPaLM-based therapy for MDR-TB.

We report the clinical course, microbiologic data, treatment regimen, and serial neuroimaging of a man in his 30s with pulmonary MDR-TB, pleural involvement, and a small peripherally enhancing cerebellar lesion compatible with a tuberculoma.

The patient presented with respiratory symptoms and mild headache, and was diagnosed with cavitary pulmonary tuberculosis, pleural involvement, and a small left cerebellar lesion. Further evaluation showed no ataxia, dizziness, or focal neurologic deficits. Sputum acid-fast culture was positive for Mycobacterium tuberculosis, and rapid molecular testing demonstrated rifampin resistance. Whole-genome sequencing confirmed resistance to rifampin, isoniazid, and ethambutol, and did not identify mutations associated with resistance to pyrazinamide, fluoroquinolones, linezolid, clofazimine, or bedaquiline. Treatment was transitioned to BPaLM (bedaquiline, pretomanid, linezolid, moxifloxacin) with adjunctive corticosteroids early in the course. Sputum cultures converted to negative approximately 6 weeks after treatment initiation. Serial brain MRI demonstrated progressive reduction in lesion size at 9 weeks, residual punctate enhancement at 21 weeks, near-complete resolution by 44 weeks, and complete radiographic resolution on subsequent imaging. The patient completed 52 weeks of therapy and remained clinically stable, without neurologic deficits or relapse more than 2 years after treatment completion.

This case describes radiographic resolution of a small presumed cerebellar tuberculoma during extended BPaLM/BPaL-based therapy for disseminated MDR-TB, highlighting the evidence gap for standardized all-oral regimens in CNS drug-resistant tuberculosis.