Facial Weakness, Diplopia, and Fever in a 31-Year-Old: An Atypical Case of Tuberculous Meningitis

Ahmed H Qavi,Zachariah Hasan,Fariha Ilyas,Tasnim F Imran

doi:10.7759/cureus.1918

Abstract

Tuberculous meningitis (TBM) is an infection of the central nervous system (CNS) meninges that carries high morbidity and mortality. It is important to recognize, as patients may present with atypical symptoms. We describe the case of a 31-year-old man with a history of diabetes who presented with a sub-acute onset of right-sided facial weakness and right gaze difficulty with diplopia. History revealed low-grade fever, right-sided headache, fatigue and moderate weight loss for the past several weeks. The patient did not report neck stiffness, rigidity, fever, chills or cough. The physical exam revealed sixth nerve palsy with a right Horner’s syndrome. Magnetic resonance imaging (MRI) of the brain showed pachymeningeal enhancement. A spinal tap revealed elevated white blood cells (WBCs), glucose and protein; cerebrospinal fluid (CSF) culture showed Mycobacterium tuberculosis. The patient was diagnosed with TBM and treated with isoniazid, rifampin, pyrazinamide, ethambutol and vitamin B6 for 12 months.The timely diagnosis of TBM can be challenging due to a nonspecific clinical presentation. In patients with a sub-acute onset of headache, fever and meningeal signs, TBM should be considered in the differential. If suspected, treatment should be initiated immediately to prevent further neurological impairment and death.

Highlights

Tuberculous meningitis (TBM) is the most lethal type of extrapulmonary tuberculosis and is especially severe in immunocompromised patients [1,2]
TBM is usually diagnosed on the basis of clinical evidence that is combined with neuroimaging abnormalities, laboratory findings and cerebrospinal fluid changes [2]
We report a case with an atypical presentation of TBM in a diabetic patient

Summary

Introduction

Tuberculous meningitis (TBM) is the most lethal type of extrapulmonary tuberculosis and is especially severe in immunocompromised patients [1,2]. A 31-year-old man with a history of diabetes presented with a right-sided facial weakness for three weeks. He reported low-grade fever, right-sided headache, tiredness and fatigue for the past month. The patient did not have chills, cough or other illnesses His past medical history was positive for diabetes, diagnosed nine months ago. Magnetic resonance imaging (MRI) of the brain was obtained due to neurological deficits It showed pachymeningeal and diffuse homogenous dural enhancement along with asymmetric tentorial enhancement, which is an uncommon finding in TBM (Figure 2). The patient was immediately started on anti-tubercular therapy He was inducted on isoniazid, 2017 Qavi et al Cureus 9(12): e1918. The patient’s fever subsided after 3 weeks His follow-up MRI after 2 months showed no significant changes. His MRI at 10 months showed complete resolution of the abnormal enhancements

Discussion

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Disclosures

Garg RK