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Abstract Details

A critically ill patient with central nervous system tuberculosis and negative initial screening workup
Infectious Disease
P12 - Poster Session 12 (12:00 PM-1:00 PM)
13-013

To describe a case of CNS tuberculosis and discuss initial workup and treatment in the setting of initially negative screening tests.
Central nervous system (CNS) involvement accounts for about 5-10% of extra-pulmonary tuberculosis (TB) and is present in approximately 1% of all TB cases. The diagnosis of CNS TB can be difficult; a high degree of suspicion is critical.
Case report
 A 62-year-old male with history of Parkinson’s disease was admitted to a community hospital with altered mental status after developing upper respiratory symptoms after attending a cultural festival. His initial LP had WBC of 190 with monocytic predominance (87%, 13% polymorphonuclear cells), a red blood cell count of 44, glucose of 18, and protein of 235. He was started on vancomycin, ceftriaxone, ampicillin, acyclovir, and dexamethasone. MRI brain demonstrated interval development of hydrocephalus; leptomeningeal enhancement, most prominent in the bilateral frontal lobes; a left anterior cerebral artery territory infarct; and evidence of basilar meningitis. An MRI of the total spine showed leptomeningeal enhancement. The patient’s serum QuantiFERON-TB Gold test was negative when checked originally, as was a repeat 3 days later. An acid-fast bacilli CSF smear and culture were also initially reported as negative. The patient progressed to lose brainstem reflexes. Autopsy showed opacification of the meninges which stained positive for AFB. Two days after the autopsy, the original CSF AFB culture resulted with growth of Mycobacterium tuberculosis complex.
Empiric anti-tuberculous therapy should not be delayed in patients with a strong clinical suspicion for TB. Because confirmatory TB testing may be difficult to obtain, early and empiric treatment when there is concern for CNS TB may result in improved outcomes for patients. GeneXpert returns diagnostic results within hours, making it the preferred test for investigating TB meningitis even when initial screening tests are negative.
Authors/Disclosures
Adeel Zubair, MD (Yale University School of Medicine)
PRESENTER 		Dr. Zubair has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for The MedNet.
Mark Landreneau, MD (Yale University) No disclosure on file
Jens Witsch, MD (University of Pennsylvania) Dr. Witsch has a non-compensated relationship as a editorial team member with Neurology Reisdent & Fellow section that is relevant to Â鶹´«Ã½Ó³»­ interests or activities.
No disclosure on file
No disclosure on file
Kevin N. Sheth, MD, FÂ鶹´«Ã½Ó³»­ (Yale UniversityDivision of Neuro and Critical Care) Dr. Sheth has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Ceribell. Dr. Sheth has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Zoll. Dr. Sheth has received personal compensation in the range of $10,000-$49,999 for serving on a Scientific Advisory or Data Safety Monitoring board for NControl. Dr. Sheth has received stock or an ownership interest from Astrocyte. Dr. Sheth has received stock or an ownership interest from Alva. The institution of Dr. Sheth has received research support from Biogen. The institution of Dr. Sheth has received research support from Novartis. The institution of Dr. Sheth has received research support from Bard. The institution of Dr. Sheth has received research support from Hyperfine. Dr. Sheth has received intellectual property interests from a discovery or technology relating to health care.
David Y. Hwang, MD, FÂ鶹´«Ã½Ó³»­ (University of North Carolina School of Medicine) The institution of Dr. Hwang has received research support from NIH. The institution of Dr. Hwang has received research support from Neurocritical Care Foundation. Dr. Hwang has received personal compensation in the range of $10,000-$49,999 for serving as a Associate Medical Director with New England Donor Services.