SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Mycobacterium tuberculosis (TB) is the leading infectious cause of death in adults worldwide (3). Only 1% of patients with TB infection have CNS involvement and it is exceptionally rare in North America (1,2). Typical manifestations of CNS infection include meningitis, tuberculoma, or abscess (2). The most common presenting symptoms are fever, vomiting, headache, and altered consciousness (1,2). CNS infection can have devastating consequences such as hydrocephalus, brain tissue damage, and cerebral vasculitis (2). This is a case of TB meningitis in North America with both brain and iliopsoas TB abscess formation following initiation of methotrexate. CASE PRESENTATION: 75-year-old female presented to outside ER with weakness, fatigue, and vomiting. She was discharged home and instructed to stop methotrexate as her symptoms were an adverse reaction. Methotrexate was started four days earlier for polymyalgia rheumatica. Two days later she became difficult to arouse and minimally responsive. CT abdomen and pelvis showed rim-enhancing collection in the right iliacus with brain MRI showing scattered punctate lesions. Empiric antibiotics, pan culturing including CSF, and iliopsoas abscess drainage and culture was performed. CSF showed low glucose and high protein indicating bacterial infection. However, all cultures showed no growth. Patient continued to be non-responsive with increasing oxygen requirements. Bronchoscopy was performed as well as PET scan which showed increased uptake in left supraclavicular and mediastinal nodes. Lymph node biopsy showed caseating granulomatous inflammation. With these findings, spinal fluid from prior lumbar puncture was sent for mycobacterial culture and PCR. Family reported the patient’s husband had active tuberculosis 2 years prior and the patient was treated prophylactically with 4 months of rifampin. Ultimately, PCR of spinal fluid and bronchoalveolar lavage returned positive for TB. Mycobacterial cultures of CSF fluid and iliopsoas abscess fluid also grew TB. DISCUSSION: Tuberculosis meningitis is the most common CNS manifestation of tuberculosis infection (1,5). Prompt initiation of anti-tuberculosis drugs and corticosteroids is critical as these patients often have irreversible CNS damage (4,5). The unknown exposure history was a key factor in directing the diagnosis and initiation of treatment in this case. Our patient responded well to dexamethasone, rifampin, pyrazinamide, levofloxacin and ethambutol. However, her mentation never returned to baseline, showing the severity and devastation CNS TB. CONCLUSIONS: Ultimately the patient’s latent TB was likely activated by the immunosuppression from methotrexate. This is something to contemplate in any patient before starting an immune altering drug. TB should be considered in altered mental status with CSF signs of bacterial meningitis without growth on cultures. Reference #1: 1.Chin JH. Tuberculous meningitis: Diagnostic and therapeutic challenges. Neurol Clin Pract. 2014;4(3):199–205. doi:10.1212/CPJ.0000000000000023 Reference #2: 2.Hamid Changal, K. (2014). Central Nervous System Manifestations of Tuberculosis: A Review Article. Mycobacterial Diseases, 04(02). Reference #3: 3.WHO. Treatment of tuberculosis: guidelines: 4th ed. Available at: http://www.who.int/tb/publications/2010/9789241547833/en/index.html. Accessed May 12, 2019 4.Tuberculous meningitis. Garg RK. Acta Neurol Scand. 2010;122:75–90. DISCLOSURES: No relevant relationships by Muhammad Ahmed, source=Admin input No relevant relationships by Alyson Bundy, source=Web Response No relevant relationships by Simon Meredith, source=Web Response No relevant relationships by karan Singh, source=Web Response No relevant relationships by Rodney Steff, source=Web Response