A 21-year-old male immigrant from Afghanistan presented with seizures 2 years previously. MRI brain was suggestive of a possible low-grade glioma affecting the right temporal lobe. After 2 years, he re-presented with symptoms of headache, intermittent pyrexia, raised intracranial pressure (opening pressure of >42 cm/H2O) requiring ventriculoperitoneal shunt to preserve his vision. MRI head revealed slight progression in appearance within the right medial temporal lobe and extension into the right cerebral peduncle with enhancement of the basal meninges as well as 7th and 8th nerve complexes. CSF consistently showed two-digit lymphocytes, with raised protein and moderately reduced glucose ratio. Large CSF samples for cytology and flow-cytometry, Acid-Fast-Bacilli, and IgG subtypes remained negative. He had lymphopaenia. CT body/PET scans revealed no lymphadenopathy. Originally, tuberculosis was considered and quadruple anti-tuberculosis therapy was given along with oral Prednisolone. His first negative tuberculosis culture after 6 weeks coincided with increasing widespread leptomeningeal spread into the intradural spinal cord. Brain biopsy from the basal leptomeninges and temporal lobe confirmed anaplastic astrocytoma.Conclusion
Anaplastic astrocytoma can present as aggressive and diffuse leptomeningeal brain and spinal disease mimicking CNS tuberculosis. Persistently negative Acid-Fast-Bacilli from the CSF samples should prompt consideration of less typical primary brain tumours.