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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 4  |  Page : 461-463

Recurrent central nervous system tuberculoma with tubercular meningitis: Swerving from asymptomatic disease to severe form


1 Department of Anaesthesiology and Critical Care, Armed forces Medical College, Pune, Maharashtra, India
2 Department of Orthopaedics, INHS, Mumbai, Maharashtra, India

Date of Submission01-Oct-2020
Date of Decision25-Nov-2020
Date of Acceptance20-Oct-2020
Date of Web Publication15-Dec-2020

Correspondence Address:
Shalendra Singh
Department of Anaesthesiology and Critical Care, Armed forces Medical College, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_184_20

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  Abstract 


Tuberculosis (TB) is known for its varied presentation and complications, the most dreaded complication being central nervous system (CNS) TB which includes tuberculoma. We present a case report of an asymptomatic recurrent case of CNS tuberculoma requiring multiple surgeries and prolonged critical care management.

Keywords: Critical care management, meningitis, tuberculoma, tuberculosis


How to cite this article:
Singh S, Sreenivasulu P, Gupta N, Sood M, Ambooken GC. Recurrent central nervous system tuberculoma with tubercular meningitis: Swerving from asymptomatic disease to severe form. Int J Mycobacteriol 2020;9:461-3

How to cite this URL:
Singh S, Sreenivasulu P, Gupta N, Sood M, Ambooken GC. Recurrent central nervous system tuberculoma with tubercular meningitis: Swerving from asymptomatic disease to severe form. Int J Mycobacteriol [serial online] 2020 [cited 2021 Jan 24];9:461-3. Available from: https://www.ijmyco.org/text.asp?2020/9/4/461/303454




  Introduction Top


Tuberculosis (TB) is one of the oldest diseases known to humankind which is caused by bacterial species termed Mycobacterium tuberculosis complex. In humans, mycobacterium TB is the main causative organism. Despite the vast spectrum of drugs available for its treatment, this disease is among the diseases with the highest morbidity and mortality and is the most prevalent bacterial disease in India.[1] TB is known for its varied presentation and complications, the most dreaded complication being central nervous system (CNS) TB which includes tuberculoma.[2],[3],[4] We present a case report of an asymptomatic recurrent case of CNS TB requiring multiple surgeries and prolonged critical care management.


  Case Report Top


Our patient is a 32-year-old male (weight: 67 kg, height: 174 cm, and body mass index: 22.1 kg/m2) diagnosed case of CNS TB for 8 years. The patient was declared treated as per the Revised National TB Control Program guidelines after 1 year completed anti-tuberculosis treatment (ATT) course. On follow-up, magnetic resonance imaging (MRI) of the brain revealed signs of recurrence of tuberculoma with dural enhancement with cerebrospinal fluid study confirming meningitis. However, the patient had no signs and symptoms concerning CNS. The patient was restarted on standard ATT (isoniazid [H], rifampicin [R], pyrazinamide [Z], and ethambutol [E]) along with dexamethasone, levetiracetam, and pyridoxin. One month into the restart of ATT patient reported to the hospital with complaints of drowsiness, generalized weakness, altered gait, and gradual onset of slurred speech for the past 4 days. In history, the failure of compliance with oral dexamethasone was reported by the patient. The patient was admitted and was started on injection dexamethasone 6 mg, thrice a day and rest treatment was continued. Symptomatic improvement was reported during the hospital stay while the patient was on injectable steroids.

After 3 weeks of uneventful hospital stay, the patient started with headache, giddiness, right-sided double vision, and left side weakness. An urgent computed tomography of the brain revealed lesion in the right gangliocapsular region with a compression effect of perilesional diffuse edema involving right temporoparietal white matter, midbrain, and pons leading to obstructive dilatation of the left lateral ventricle and midline shift of 7.4 mm toward left. The patient was managed with injection mannitol and pulse doses of injection methylprednisolone. Injection streptomycin was added to the standard ATT regimen and the patient was planned for emergency ventriculoperitoneal (VP) shunting under general anesthesia (GA) for obstructive hydrocephalus. VP shunting under GA was uneventful; however, the patient was not extubated in view of preoperative gradually dipping sensorium. The patient was shifted to the intensive care unit (ICU) and was placed on mechanical ventilation with other supportive ICU care. The postoperative period was uneventful and the patient was successfully extubated on the third postoperative day. On the 7th postoperative day, an urgent noncontrast computer tomography was done following a dip in sensorium which revealed an increase in perilesional edema with mass effect and a midline shift of 15 mm associated with right-sided uncal herniation [Figure 1]. Emergency right frontotemporoparietal decompressive hemicraniectomy was undertaken under GA which was uneventful, and the patient was shifted to ICU intubated on mechanical ventilation. During the postoperative course of events, from the third postoperative day of the second surgery, the patient's liver function tests revealed transaminitis which was addressed by modifying the ATT regime wherein HRZ was stopped and levofloxacillin was added.
Figure 1: Postoperative noncontrast computer tomography revealed an increase in perilesional edema with mass effect and a midline shift of 15 mm associated with right-sided uncal herniation

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The patient was continued on mechanical ventilation with measures to prevent ventilator-associated pneumonia and other ICU supportive care. The patient's sensorium continued to remain poor throughout the postoperative period with the best Glasgow Coma Scale of E1VTM4 till the 12th postoperative day. Anticipating the requirement of prolonged mechanical ventilation in view of the persistent poor sensorium, percutaneous tracheostomy was performed on the 13th postoperative day. MRI and magnetic resonance angiography on the 15th postoperative day showed postcraniectomy and post-VP shunt status, tuberculomas in right-sided gangliocapsular, thalamus, and periventricular region with significant mass effect [Figure 2]. Possible ischemic infarcts in bilateral occipital lobes and large hematoma at the operated site. On the 14th postoperative day, the patient had uncontrolled intermittent seizures which were controlled with infusion midazolam infusion and addition of oral phenobarbitone. The patient continued to receive airway and supportive ICU care along with modified ATT. On the 25th postoperative day, the patient was started on T-piece following a successful spontaneous breathing trial.
Figure 2: Magnetic resonance imaging scan of the brain done on the 15th postoperative day showed postcraniectomy and postventriculoperitoneal shunt status, tuberculomas in right-sided gangliocapsular, thalamus, and periventricular region with significant mass effect

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  Discussion Top


CNS TB is one of the serious forms of TB infection which is associated with high morbidity and mortality. CNS TB accounts for 1% of all TB cases and 5%–8% of extrapulmonary TB cases.[5],[6] Risk factors for CNS TB include pediatric age group, human immunodeficiency virus infected individuals, malnutrition, recent measles in children, alcoholism, malignancies, and the use of immunosuppressive agents in the adults.[2],[7] None of these risk factors were present in our case. Diagnosis remains a challenge and is usually delayed even with the availability of varied diagnostic techniques including molecular techniques, due to varied clinical and neuroimaging presentation and insensitive microbiological methods.[8],[9]

Relapse in CNS TB is not uncommon and has been reported with an incidence of 3%.[2],[10] Our case had a recurrence for which ATT was reinstituted which was followed by flaring of symptoms. Flaring of symptoms can be attributed to immune reconstitution inflammatory syndrome (IRIS). Predictors of poor prognosis concerning CNS TB present in our patient included decreased mental status, focal neurological deficits, cranial nerve palsies, the requirement of mechanical ventilation, and delayed or interrupted treatment.

TB patients in ICU present special challenges, including obtaining microbiological confirmation, providing effective ATT with poor absorption and high rates of organ dysfunction, and apparent deterioration of TB during appropriate treatment (paradoxical reactions). Tuberculosis meningitis poses two additional particular challenges for the intensivist relevant to neurocritical care-hydrocephalus and hyponatremia.

Our patient though diagnosed early regarding recurrence due to regular follow-up but probably due to the IRIS had a serious course of the disease. This case demonstrates that even an asymptomatic case of CNS TB can take a severe clinical course requiring a multidisciplinary team for its management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bloom BR, Atun R, Cohen T, Dye C, Fraser H, Gomez GB et al.Tuberculosis. In: Holmes KK, Bertozzi S, Bloom BR, et al., editors. Major Infectious Diseases. 3rd ed.,Ch. 11. Washington (DC): The International Bank for Reconstruction and Development/The World Bank; 2017.  Back to cited text no. 1
    
2.
Cherian A, Thomas SV. Central nervous system tuberculosis. Afr Health Sci 2011;11:116-27.  Back to cited text no. 2
    
3.
Vaziri S, Soleiman-Meigooni S, Rajabi J, Asgari A. Tuberculous ventriculitis: A rare complication of central nervous system tuberculosis. Int J Mycobacteriol 2016;5:231-4.  Back to cited text no. 3
  [Full text]  
4.
Dev N, Bhowmick M, Chaudhary S, Kant J. Tuberculous encephalopathy without meningitis: A rare manifestation of disseminated tuberculosis. Int J Mycobacteriol 2019;8:406-8.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Rieder HL, Snider DE Jr., Cauthen GM. Extrapulmonary tuberculosis in the United States. Am Rev Respir Dis 1990;141:347-51.  Back to cited text no. 5
    
6.
Centers for Disease Control and Prevention. Extrapulmonary Tuberculosis Cases and Percentages by Site of Disease: Reporting Areas. Atlanta, GA: Centers for Disease Control and Prevention; 2005.  Back to cited text no. 6
    
7.
Rock RB, Olin M, Baker CA, Molitor TW, Peterson PK. Central nervous system tuberculosis: Pathogenesis and clinical aspects. Clin Microbiol Rev 2008;21:243-61.  Back to cited text no. 7
    
8.
Patil S, Giribhattanavar P, Patil M, Kumar K. Immuno confirmation of central nervous system tuberculosis by blotting: A study of 300 cases. Int J Myco 2015;4:124-130.  Back to cited text no. 8
    
9.
Samson Ejiji I, Gomerep S, Johnson M, Basil Bemgba A. Delayed diagnosis of tuberculous meningitis in a pregnant Nigerian: A case report. Int J Mycobacteriol 2013;2:54-7.  Back to cited text no. 9
    
10.
Nelson CA, Zunt JR. Tuberculosis of the central nervous system in immunocompromised patients: HIV infection and solid organ transplant recipients. Clin Infect Dis 2011;53:915-26.  Back to cited text no. 10
    


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