A Masquerading Case of Meningitis

1Forsyth Medical Center, Winston‐Salem, NC
2Moses Cone Health System, Greensboro, NC

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 1010

Case Presentation:

A 44‐year‐old woman was admitted in early October with fever, headache, and malaise. She was employed in an elementary school cafeteria where there had been several sick children. She was treated empirically with vancomycin and ceftriaxone, and although she clinically improved, her fever persisted. Lumbar puncture (LP) yielded 41 white blood cells with 69% lymphocytes, glucose 34, and protein 82. After 6 days of treatment and negative culture results, she was discharged home off antibiotics. Unfortunately, she experienced a progressive decline in her mental status and 1 month later was taken by her family to the emergency room for a witnessed seizure. A computed tomography scan of the head demonstrated cerebritis and a communicating hydrocephalus. Magnetic resonance imaging revealed diffuse leptomeningeal hyperemia and enhancement consistent with meningitis, along with diffuse cerebral edema consistent with encephalitis. There were also scattered small abscesses in the corpus callosum, subcortical right frontal lobe, and left temporal lobe. Lumbar puncture yielded 209 white blood cells with 98% lymphocytes, glucose of 11, and protein of 416. Empiric treatment for meningitis was begun with vancomycin, ceftriaxone, and high‐dose steroids. An antituberculosis regimen was also initiated based on the chronicity of her symptoms and continued even though the protein purified derivative and chest x‐ray were negative. Despite multiple efforts, she could never provide sputum for analysis. Given the high clinical suspicion and pending acid‐fast bacilli (AFB) cultures, QuantiFERON gold test and polymerase chain reaction of the cerebrospinal fluid (CSF) were obtained for Mycobacterium tuberculosis (TB), but were negative and equivocal, respectively. Extensive investigation was undertaken, including brain biopsy and comprehensive serology testing. The possibility of lymphoma, opportunistic infections, and fungal infections was explored without conclusive diagnosis. Following 5 therapeutic lumbar punctures over her 2‐month hospital course, she regained some cognitive function. Forty‐two days after her readmission and LP, an AFB culture from her CSF returned positive for Mycobacterium tuberculosis. She continued on a full course of treatment for tuberculosis and has largely regained full cognitive function.

Discussion:

TB can present in myriad forms and mimic other more common illnesses. Although usually pulmonary, TB can affect other organs, including the brain. Tuberculous meningitis (TbM), accounts for 1% and 6% of all TB and extrapulmonary TB cases, respectively. Although nationally TB has significantly declined, the incidence of TbM has remained stable, with 172 cases in 2004.

Conclusions:

This case is a sobering demonstration of the innumerable ways extrapulmonary TB may present. Although TbM is an extremely rare form of a rare condition, treatment should be initiated immediately if suspected and must continue until cultures are officially negative, as shown by this case.

Disclosures:

J. Cohen ‐ none; G. Scott ‐ none; K. Mills ‐ none

To cite this abstract:

Cohen J, Scott G, Mills K. A Masquerading Case of Meningitis. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 1010. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/a-masquerading-case-of-meningitis/. Accessed November 11, 2019.

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