Tuberculous Meningitis in a Healthy Young Woman: Case Report and Review of Literature (P03.250)

Abstract

Objective: To present an unusual case of an immune-competent young woman with CNS tuberculosis (CNSTB) Background CNSTB comprises 0.5%-1% of encephalitis cases. Eighty percent of CNSTB patients have foreign travel or other exposure to TB. Many reported cases of CNSTB are notable for immune-compromise. Early disease presentation includes symptoms of progressive head/neck pain, pyrexia, and anorexia. Disease progression results in meningeal inflammation, vasculitis, hydrocephalus and elevated ICP. Late clinical presentation includes confusion, hemiparesis, cranial nerve palsy and visual deficits. Without intervention these cases progress to blindness, coma and death making early recognition imperative for optimal outcome. Design/Methods: We present an immune-competent 26 year-old woman without TB exposure history with unusual presentation of CNSTB and rapid decline. We have searched the literature, identifying cases of CNSTB with attention to details of disease risk factors, presentation & progression, the role of diagnostic testing and outcome data relative to timing of treatment initiation. Results: A 26 year old immune-competent woman with CNSTB and unusual presentation of thunderclap headache. Diagnostic TB studies were initially negative. CSF with high WBC/protein, low glucose. MRI with meningeal and diffuse nodular enhancement. Clinical progression was consistent with CNSTB and empiric therapy was initiated but ineffective. The patient progressed to herniation despite optimal management. Literature review revealed 4 cases of laboratory confirmed immune-competent individuals with CNSTB. Significant literature exists on HIV patients with TB, 40% eventually developing CNSTB. Early confirmatory testing is often negative. In HIV early empiric therapy improves outcomes. No consensus exists when to start treatment in immune-competent individuals. Conclusions: Our case has several unique characteristics: she had no exposure history and was immune-competent. Her presentation was quite fulminant and atypical for CNSTB. Her decline and expiration occurred prior to confirmatory labs. CNSTB and early empiric therapy should always be considered, even in immune-competent patients, presenting with acute onset hydrocephalus to optimize outcomes. Disclosure: Dr. Mutgi has nothing to disclose. Dr. Greene-Chandos has nothing to disclose. Dr. Torbey has nothing to disclose. Dr. Behrouz has nothing to disclose.