Subdural Tubercular Empyema in an Immunocompetent Patient: A Rare Primary Presentation of CNS Tuberculosis

Abstract

Tuberculosis (TB) remains a potentially-curable serious health problem in most of the developing world including Pakistan. Subdural Tubercular Empyema is a very rare presentation of CNS tuberculosis. A 25-year-old gentleman presented with a 25-day history of low-grade intermittent fever and generalized headache. On examination, he had a temperature of 99.6oF with equally round and reactive to light pupils with normal extraocular muscle movements. However, there were signs of papilledema on fundoscopic examination. Signs' of neck rigidity (Kernig and Brudzinski) were negative. There was no focal neurological deficit. CSF analysis showed TLC 660 cells/uL with 100% lymphocytes, RBC 0 cells/uL, Protein 73 mg/dl, and Glucose 43 mg/dl with no organisms on Giemsa staining but positive AFB stain microscopy. GeneXpert-PCR for MTB was also positive on CSF with no drug resistance to rifampicin detected. His brain MRI scan showed left subdural empyema. Workup for the immunosuppressive condition was negative. He was diagnosed as having Subdural Tubercular Empyema and started on Anti-tubercular therapy. On follow-up at 4 weeks, he was asymptomatic and tolerating ATT without any adverse effects.