RARE PRESENTATION OF DISSEMINATED TB: MULTIPLE RING ENHANCING LESIONS IN BRAIN

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cerebral tuberculomas is a rare form of extrapulmonary tuberculosis (TB). Due to lack of tests available for confirmatory diagnosis, the diagnosis is difficult. However, missing the diagnosis could lead to catastrophic consequences. Here, we report a case of disseminated tuberculosis presented with multiple ring enhancing lesions in the brain. CASE PRESENTATION: A 75-year-old male presented with progressive generalized weakness associated with fever and chills for 3 weeks. He has a history of bronchial carcinoid tumor status post radiation therapy, Waldenstrom's macroglobulinemia, heart failure with reduced ejection fraction, implantable cardiac defibrillator placement, coronary artery disease, stroke, and type 1 diabetes. He appeared tired with mild symmetrical lower limb weakness, but there were no meningeal signs. CT of head revealed innumerable ring-enhancing lesions in both cerebrum, cerebellum and brainstem. Analysis of cerebrospinal fluid (CSF) showed lymphocyte predominant pleocytosis (WBC of 253/cumm), elevated protein (155 mg/dl) with low glucose ratio (CSF/serum glucose ratio of 0.4). Empirical treatment for meningitis were started, but intermittent spiking fever persisted. Unfortunately, the patient had a cardiac arrest while he was undergoing brain MRI. Postmortem autopsy revealed multiple necrotizing granulomatous nodules with AFB positive bacteria in multiple organs, including brain, lung, liver, spleen, thyroid, pulmonary and extrapulmonary lymph nodes. Mycobacterium tuberculosis complex was isolated from CSF subsequently. A diagnosis of disseminated TB was made. Upon further investigation, the patient did not have exposure history, except for travelling around the globe when he was young. DISCUSSION: The differential of multiple ring-enhancing lesions in the brain is broad, which include neurocysticercosis, toxoplasmosis, cryptococcosis, bacterial abscess, CNS lymphoma and cerebral metastases. Given the complicated medical history of our patient and lack of risk factor for TB, empirical treatment for TB was not given. In such a clinical scenario, a more sensitive test, e.g. nucleic acid amplification (NAA), would be the deciding factor for initiation of therapy. Unfortunately, there is a lack of data to support the use of NAA in patients at risk for cerebral tuberculoma. Future studies would be warranted to explore the use of NAA in the setting of extra-pulmonary tuberculosis. CONCLUSIONS: Disseminated tuberculosis is a lethal disease if missed. However, diagnosis of disseminated tuberculosis remains a huge challenge, especially when pulmonary symptoms are absent. A high index of suspicion is required to diagnose and treat disseminated tuberculosis. More researches are warranted to expedite the diagnosis of TB. REFERENCE #1: Suárez I, Fünger SM, Jung N, et al. Severe disseminated tuberculosis in HIV-negative refugees. Lancet Infect Dis 2019; 19: e352–e359. REFERENCE #2: Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: diagnosis of tuberculosis in adults and children. Clin Infect Dis 2017; 64:e1–33. DISCLOSURES: No relevant relationships by Gin Yi Lee, source=Web Response No relevant relationships by Kaiqing Lin, source=Web Response No relevant relationships by Guangchen Zou, source=Web Response