the world health organization ( who ) reported 9.27 million new cases of tb and 1.3 million tb - related deaths among human immunodeficiency syndrome ( hiv)-negative populations in 2007 . in addition , the migration is expected to contribute to the spread of the disease in both industrialized and resource - poor countries . the disease especially appears in younger objects and generally involves the lungs in the immigrant populations from high - prevalence countries . central nervous system tb is the most destructive form of tb and is associated with high mortality rates up to 60% and neurological sequel in 25% of the survivors despite the new neuroimaging techniques and effective antituberculous therapy . with this report , we aimed to create awareness about tb  especially its serious forms and complications  among clinicians who deal with immigrants . a 14-year - old child of an immigrant family , a native of azerbaijan who had been living in turkey for 10 years , presented to our clinic in september 2009 with complaints of fever , persistent headache and vomiting that lasted for 10 days . physical examination was normal except for neck rigidity , meningeal irritation sign and mild confusion . the emergent cranial computerized tomography ( ct ) without contrast on admission scan showed no pathological findings . the findings were : csf cell count , 57/mm ; leukocyte ( 60% lymphocyte ) , 18/ mm ; erythrocyte and glucose , 13 mg / dl ( simultaneous blood glucose 109 ) ; protein , 243 mg / dl . laboratory tests : wbc 12,300/mm ; hemoglobin 11.7 g / dl ; crp 12 mg / dl ; anti - hiv antibody negative . on the same day , sudden loss of consciousness , bradycardia and hypotension developed and the patient was transferred to the intensive care unit ( icu ) . ceftriaxone and acyclovir therapy was started due to clinical deterioration , loss of consciousness and seizure on the same day . a negative herpes simplex virus ( hsv ) since the patient 's mother had a pulmonary tb history and her clinical condition did not improve , antituberculous therapy with four drugs and dexamethasone was started on the second day . then , the vital findings were found to have improved on the seventh day and she transferred to the infectious diseases ward . she was evaluated as stage iii and cranial magnetic resonance imaging ( mri ) , which was performed on the seventh day with gadolinium , showed multiple tuberculoma in the basal ganglions , cerebral and cerebellar hemispheres , basal meningitis and minimal hydrocephalus [ figure 1 ] . miliary pattern was detected in the thorax ct ( hrct ) [ figure 2 ] . csf polymerase chain reaction ( pcr ) for tb ( genexpert mtb - rif , cepheid , sunnyvale , ca , usa ) and quantiferon tb gold test ( cellestis , australia ) were positive on the third day . mycobacterium tuberculosis was isolated from the csf on the 21 day in loewenstein jensen ( l - j ) medium . during the hospitalization period , convulsion , hearing loss , aphasia and motor deficits developed and the patient was discharged from the hospital on the 34 day with neurological sequel ( aphasia , motor deficits , mild mental defect and hearing loss ) . she has been followed - up in our outpatient clinic ever since . a : multiple tuberculomas and basal meningitis b : hydocephalus in cranial imaging miliary pattern in high resolution computed tomography tuberculous meningoencephalitis ( tbm ) is the most severe , life - threatening form of tb and usually carries a subacute or chronic form . headache , vomiting , fever and neck rigidity are the most common complaints and findings . complaints of this case lasted for 10 days and , therefore , her disease was accepted as an acute / subacute form . on admission , there was no neurological deficit except confusion , but she was transferred to the icu with comatose mental status on the second day . there were some factors known as predictors of poor outcome , including extreme ages , stage of illness and hydrocephalus[46 ] hosoglu and colleagues showed that drowsiness on admission is also an important predictor for neurological sequel . confusion of the case on admission was considered as a clue for poor outcome according to this report , and neurological sequel developing in the subsequent days supported this knowledge . the rate of tb history in the family or close contact with persons with active pulmonary tb is generally high in adult tbm patients in developing countries . in this case , living in poor socioeconomic conditions and crowded areas results in a high rate of positive family histories . positive family history , miliary tb , presence of hydrocephalus and multiple tuberculoma and younger age were predictive values for tbm . in addition to altered sensorium , these factors might be considered as poor prognostic factors in this case , which has clinical deterioration and neurological sequel . but , isolation of the agent may not be possible by this time - consuming process in every patient . antituberculous therapy ( att ) was started empirically on the second day in this case . however , quantiferon and tb pcr were positive on the third day while culture positivity in l - j medium was obtained on the 21 day . helpful diagnostic procedures like pcr or neuroradiological findings or presence of pulmonary tb may shorten this duration and provide early diagnostic advantages . basal meningitis and multiple tuberculoma were detected in cranial mri in this case , whereas urgent cranial ct scan was normal . indeed , a recent study mentioned the more diagnostic and more predictive facilities of mri for poor outcome in patients with tbm than ct . therefore , we suggest that clinicians should perform cranial mri and chest x - ray to detect radiological clues for tb or other helpful laboratory tests like pcr and quantiferon as soon as possible to shorten the diagnosis period . tuberculomas are the most common forms of central nervous system tb and comprise 534% of all intracranial masses , which may be confused with other space - occupying lesions . they may be seen solitary , but multiple ones are more common . in this case , multiple tuberculomas that were noncaseating , located both in cerebral and cerebellar regions and sized less than 2 cm were detected in cranial mri . basal meningeal enhancement , hydrocephalus and basal ganglia infarctions consist of the common triad of neuroradiological findings . although early diagnostic procedures and follow - up ct were performed and steroid treatment was administered in the early stage , developing neurological sequel could not be prevented in this case . thus , we suggested that there may be other poor prognostic factors such as immune system of the patient . the detailed evaluation on admission and early diagnosis may contribute to the prevention of severe complications and death arising from delayed therapy in tbm , but this attitude is not valid every time and in all patients . tb is a global disease that travels in and between populations due to migration . in conclusion , physicians should be aware of central nervous system tb besides the pulmonary forms of tb in immigrant populations . detailed evaluation of these patients on admission may prevent poor outcomes of tbm related with delayed diagnosis and therapy .
central nervous system tuberculosis ( tb ) is the most devastating manifestation of tb . 
 it is a challenge for clinicians because of the difficulty in making an early diagnosis and the severe consequences of delayed treatment . 
 the aim of this report is to point out the relation between migration and tb based on a 14-year - old child with tuberculous meningoencephalitis ( tbm ) of an immigrant family . 
 migration , crowded living conditions and positive family history contribute to the severe course of tb as tbm and miliary tb forms . 
 tb control may prevent these severe manifestations of the disease among immigrants . 
 prompt diagnosis with helpful early diagnostic tools like polymerase chain reaction in tbm is crucial due to the high mortality and morbidity .