Unusual presentation of tuberculous meningitis: Two case reports

Abstract

Introduction Central nervous system tuberculosis is a serious health problem worldwide and accounts for more than 7% of all cases of tuberculosis especially in developing countries with high prevalence of tuberculosis and also should be considered in high risk patients or in patient emigrated from regions with a high prevalence of tuberculosis. Tuberculous radiculomylitis is a complication of tuberculous meningitis which has been infrequently reported in medical literature. Case description Case I: A 49-year-old previously healthy Filipino female with 5 days history of fever, back pain radiating to both legs followed by acute onset of lower limb weakness and urine retention one day prior to presentation. Physical examination revealed pyrexia, alert patient, no sign of meningeal irritation and lower limb power decrease (3/5) normal exam of upper limb. Investigation showed elevated WBC in Cerebral Spinal Fluid (60% lymphocyte). Positive PPD and positive quantiferon test. MRI showed extensive enhancement around nerve roots extending cranially to lower thoracic. Patient started on antituberculous treatment, steroid and physiotherapy. Six month post treatment did not show significant neurological improvement, but fever respond after start of treatment. Case II: A 27-year-old healthy Filipino female, presented with history of fever, headache, neck and back pain with vomiting, three weeks prior to presentation and was treated as case of otitis media with two different antibiotic given during two primary health care visits. Presented with one day lower abdominal pain with urinary retention and body weakness. Physical exam showed lethargic patient afebrile with spastic quadriparesis power of upper limb 4/5 and lower limb 3/5. Investigation showed cerebrospinal fluid, high WBC (90% lymphocyte), high CSF protein and low glucose. High serum ESR. MRI showed increase leptomeningeal enhancement of spinal cord extending to the pons. Patient also started on steroid and antituberclous drugs. Patient made good clinical recovery and discharged. Results and conclusions In patient with tuberculous meningitis, an early diagnosis and initiation of therapy plays a major role in preventing unnecessary morbidity and mortality. In several series, use of the steroid has been considered beneficial and should be given for secondary neurological complications, associated with tuberculous meningitis. Emergency clinician must be aware of unusual presentation of tuberculous meningitis and other different causes of lower limb weakness. Neuroimaging with MRI with and without contrast and lumber puncture is critical for diagnosis.