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Título

Neurotuberculosis in an immunocompetent patient: a case-based update

RESUMO

CASE PRESENTATION: A 35-year-old man was admitted 1 month ago with paraparesis and thunderclap headache. He reports a chronic condition of nausea, vomiting, diarrhea, recurrent fever and monoparesis in the left lower limb for 3 months. A skull Magnetic Resonance Imaging (MRI) was performed, showing important hydrocephalus with diffuse nodules in the leptomeninges. A ventriculoperitoneal shunt was installed, with partial neurological improvement. There was a condition worsening 2 weeks ago, with extension to a tetraplegia associated with ascending paresthesia to the T9-T10 level. Neurological examination revealed global areflexia, central nystagmus, right peripheral facial palsy and partial neck stiffness. Laboratory tests showed negative bacterioscopy, blood cultures, sputum smear microscopy, rapid tests for HIV and VDRL. Chest computed tomography (CT) revealed no lung lesions, and T2 FLAIR MRI of cervical-thoracic spine and skull showed hypersignal in broad sites of telencephalon, brainstem, cerebellum, and C3-T8 spinal cord. Cerebrospinal fluid (CSF) examination revealed cellularity of 60/mm3, proteins of 146 mg/dl, glucose of 28 mg/dl, negative VDRL and bacterioscopy, no fungal growth on India ink stain, and adenosine deaminase (ADA) of 26 U/L, which confirmed the diagnosis of neurotuberculosis. A regimen of rifampicin, isoniazid, pyrazinamide and ethambutol was started, to which the patient has been evolving with paraparesis improvement.
DISCUSSION: Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis that mainly affects lungs, but can also affect the meninges, causing neurotuberculosis (3% of TB cases in seronegative HIV patients). There is slower subacute evolution than other meningitis. Clinical response to treatment is excellent when it is diagnosed before irreversible neurological damage, so empiric therapy should be initiated immediately in any patient with neurological abnormalities, CSF with low glucose concentration, high protein, lymphocytic pleocytosis and if TB is suspected. Higher ADA levels in CSF are useful in diagnosis. Hydrocephalus and basal meningeal thickening are common findings in CT or MRI. Treatment is initially composed by a four-drug regimen including isoniazid, rifampicin, pyrazinamide and ethambutol daily for 2 months.
FINAL COMMENTS: The diagnosis of neurotuberculosis in immunocompetent patients can be challenging and lead to high mortality if not diagnosed soon.

Palavras Chave

neurotuberculosis, meningoencephalitis, hydrocephalus