Background: Diagnosing central nervous system (CNS) tuberculosis is challenging because of its rarity, indolent course, and insensitive microbiological diagnosis. The mortality of the disease is high even with prompt initiation of appropriate therapy. Case report: A 36-year-old male from Pakistan with no past medical history was brought to the hospital with fever (39o C) and altered behavior since 2 weeks. He was confused, with nuchal rigidity, an enlarged right cervical lymph node and swelling of the left knee and ankle. The first brain CT was normal. Lumbar puncture revealed lymphocytic pleocytosis with elevated protein and low glucose. He was started on ceftriaxone, ampicillin and acyclovir pending further cerebrospinal fluid (CSF) analysis. CSF acid-fast staining, tuberculin skin test, CSF PCR for mycobacterium tuberculosis, testing for HIV, Cryptococcus and syphilis were all negative. Due to the patient’s worsening neurological status, a brain MRI was performed revealing worsening hydrocephalus, leptomeningeal enhancement and brain edema, findings consistent with tuberculous central nervous system infection. A ventriculostomy was placed and he was started on anti-tuberculosis therapy and adjunctive prednisone. The diagnosis of tuberculosis was later confirmed from culture of the CSF. Synovial fluid analysis revealed 30 leukocytes/ul, with negative cultures (suggesting Poncet’s disease). Despite improvement of the level of conscience, neurological improvement was otherwise limited, and the patient died 4 months later after repeated in-hospital infections. Discussion: Considering the morbidity and mortality of CNS tuberculosis empirical initiation of therapy is important when the clinical suspicion is high.
Tryst and treatment of an unusual case of MDR CNS tuberculosis
