ABSTRACT
Neurocysticercosis (NCC) and central nervous system tuberculosis (CNS TB) are two of the most common causes of ring-enhancing lesions in the brain in endemic regions. Their overlapping clinical and radiological features often pose diagnostic dilemmas and challenges, which can delay appropriate treatment. We report the case of a 55-year-old female from Uttarakhand, India, who initially presented with low-grade fever and holocranial headache. Initial CE-MRI suggested NCC, and she was started on albendazole and corticosteroids with partial relief. Two months later, she developed a worsening headache with altered sensorium. Repeat imaging revealed hydrocephalus, and CSF analysis showed elevated protein, hypoglycorrhachia, lymphocytic pleocytosis. Confirmatory testing with CBNAAT of CSF and endotracheal aspirate detected Mycobacterium tuberculosis, establishing the diagnosis of disseminated TB. She was started on ATT and dexamethasone, which led to gradual improvement in sensorium and resolution of fever. This case highlights diagnostic complexity in differentiating NCC from CNS TB solely based on imaging. It underscores the importance of integrating microbiological investigations like CBNAAT in patients with atypical progression or poor response to antiparasitic therapy, especially in tuberculosis-endemic areas.