Cerebral salt wasting in a case of tubercular meningitis in a child

Abstract

A 12-year-old female child presented with fever, headache, vomiting since 20 days and convulsions for 1 day. She was unimmunised and BCG scar was absent. Clinical examination showed signs of meningeal irritation, Kernigs sign and Brudzinkins sign with signs of raised intracranial tension. Fundus examination was suggestive of stage 2 papilledema. Her laboratory reports were normal on admission. LP was with hold in view of raised ICT. CT brain was done. S/O meningeal enhancement, mild communicating hydrocephalus with periventricular ooze, extra axial hyper densities in bilateral sylvian fissures along the tentorium (Basal Exudates) On day 3 of admission she had low serum sodium, serum osmolality High urinary sodium. While on lumbar puncture (LP) and cerebrospinal fluid (CSF) examination, CSF protein, and total leukocyte count (predominant lymphocytes) were all increased. On his 5th day of admission, her serum sodium was low and he had a normal urine output. Fluid restriction was tried in order to rule out syndrome of inappropriate antidiuretic hormone secretion (SIADH) but the patient did not respond to it. Keeping in view the above findings, a final diagnosis of tuberculous meningitis leading to cerebral salt wasting syndrome was made. The patient was started on anti-tuberculous therapy (ATT), IV Steroids, anticonvulsants, 3% NaCl and supportive treatment, to which she responded favourably and was later discharged.