Tuberculous Meningitis in an Immunocompetent Man Presenting as Change in Mental Status

1Geisinger Health System, Danville, PA
2Geisinger Health System, Danville, PA

Meeting: Hospital Medicine 2008, April 3-5, San Diego, Calif.

Abstract number: 143

Case Presentation:

A 68‐year‐old Filipino man with a medical history of COPD, tobacco abuse, and transient ischemic attacks, presented to an outside hospital with complaints of change in mental status, an approximate 30‐pound weight loss over 2 months, an unsteady gait, and diffuse weakness. The patient's wife described a chronic cough and memory problems. An admission chest x‐ray at the outside hospital was thought to disclose a pulmonary nodule and possible infiltrate. He was treated for infection but because of continued confusion and leukocytosis, the patient was transferred to our facility, and a lumbar puncture was performed. It revealed a protein of 1528, glucose of 78, 97 white cells with 94% lymphocytes, and 4600 red cells. The gram stain and culture were negative. A CT of the chest showed a 1.9‐cm cavitary nodule in the left upper lobe. A PPD was initially negative, but because of the high index of clinical suspicion, he had a repeat PPD placed that showed 25 mm of induration. A bronchoscopy with washings was performed that showed an unresolving left upper lobe infiltrate. Clinical concern for tuberculosis was high, and a 4‐drug regime was started. MRI/MRA was done because of the patient's waxing and waning mental status and abnormal lumbar puncture results. It showed extensive leptomeningeal enhancement of the basal cisterns and a very poor flow signal in the right posterior cerebral artery and right superior cerebellar artery. This was correlated with a CT of the head that showed acute cerebellar infarcts. These were thought most likely to be secondary to tuberculous meningovasculitis. MTB was detected by a DNA probe done on the bronchoscopy washings. This, along with the other imaging and clinical history, led to the diagnosis of tuberculous meningitis complicated by meningovasculitis and acute ischemic strokes.

Discussion:

This patient illustrates a rare disease presenting as a common cause of hospital admission in elderly patients: change in mental status. TB meningitis requires a high index of suspicion to diagnose, the prodrome is nonspecific, but headache and mental status changes are more common in the elderly. TB meningitis can cause basal vasculitis with secondary infarctions. Risk factors include immunosuppression, malnutrition, alcoholism, substance abuse, malignancy, and head trauma. CSF analysis is difficult to rely on, as only 50%‐80% of known TB meningitis patients have positive results. PCR is a rapid and reliable way to make the diagnosis but could have false‐negative results.

Conclusions:

TB meningitis requires a high index of clinical suspicion. AFB are hard to culture, and the culture process is time consuming, other labs (DNA probe, PCR) should be considered early on while not delaying empiric treatment. Mental status changes are consistent with a poorer prognosis, whereas early treatment usually ends in better outcomes.

Author Disclosure:

R. Puher, none; S. Girard, none.

To cite this abstract:

Girard S, Puher R. Tuberculous Meningitis in an Immunocompetent Man Presenting as Change in Mental Status. Abstract published at Hospital Medicine 2008, April 3-5, San Diego, Calif. Abstract 143. Journal of Hospital Medicine. 2008; 3 (suppl 1). https://www.shmabstracts.com/abstract/tuberculous-meningitis-in-an-immunocompetent-man-presenting-as-change-in-mental-status/. Accessed November 13, 2019.

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