Tuberculous Meningitis in a Honduran Immigrant

1Carilion Clinic–Virginia Tech Carilion, Roanoke, VA

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

Abstract number: 245

Case Presentation:

A 43‐year‐old woman without any medical history presented to the emergency room with a severe headache, neck pain, chills, vomiting, and photophobia for 7 days. She also had complaints of recent loss of appetite and fatigue. She had immigrated from Honduras 4 years previously. She denied any sick contacts. On presentation, vital signs were normal, but the patient looked uncomfortable. She had a supple neck and negative Kernig/Brudzinski signs and was neurologically intact. Lumbar puncture revealed an opening pressure of 29 cm H2O, glucose 32 mg/dL, and protein > 300 mg/dL, and gram stain showed white blood cells without organisms. The patient was treated with vancomycin, ceftriaxone, acyclovir, fluconazole, and methylprednisolone. Antibodies to toxoplasma and coccidiomycosis, along with the cryptococcal antigen and HSV polymerase chain reaction (PCR) testing were negative. Testing for HIV was negative. Serum QuantiFERON Gold was positive, whereas the initial PCR for tuberculosis (TB) was negative. Repeat MTb PCR 5 days later was positive. On this repeat cerebrospinal fluid (CSF) sample, the acid‐fast bacilli smear was positive. The patient was started on TB treatment and dexamethasone but became unresponsive the following day. Magnetic resonance imaging showed hydrocephalus, basilar cistern infarction, foraminal herniation with syringomyelia, and a left tuberculoma. Despite treatment, she deteriorated and died with an intracranial pressure > 90 cm H2O.

Discussion:

The global prevalence of tuberculosis is estimated at 32% and the percentage of cases among U.S. foreigners was as high as 53% in 2003. TB affects the central nervous system in only 1% of cases; however, this form of TB is responsible for the highest mortality. TB meningitis is the most common variant of CNS TB and may progress from granulomatous meningitis to hydrocephalus and infarction if untreated.

Conclusions:

CNS TB is often considered in immunosuppressed patients, however in developed nations the highest‐risk group is in immigrants from tuberculosis‐endemic regions. Because the disease process can progress rapidly, from headache to coma in a few hours, early initiation of antituberculous treatment can avoid devastating neurological complications and death. Studies have shown a few variables that are highly suggestive of CNS TB: symptoms lasting more than 5 days, patient age > 30, and pleocytosis (≤1000 cells/mm3) with lymphocyte predominance. A CSF PCR test can make a rapid diagnosis but fails to detect TB in up to 50% of patients, such as in our case on the initial CSF sample. Treatment with a quadruple drug regimen is recommended, along with intravenous corticosteroids. Morbidity and mortality are related to the most common complication, hydrocephalus, treatment of which is still highly contested. CNS TB should be high on the differential for an immigrant patient who present with symptoms of meningitis.

Disclosures:

J. Blazo ‐ none; K. Khosa ‐ none; T. Kerkering ‐ none

To cite this abstract:

Blazo J, Khosa K, Kerkering T. Tuberculous Meningitis in a Honduran Immigrant. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 245. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/tuberculous-meningitis-in-a-honduran-immigrant/. Accessed July 19, 2019.

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