Dados do Trabalho

Título

Meningitis and spinal arachnoiditis neurotuberculosis presentation: The challenge of diagnosis

RESUMO

Case Report

A previously healthy 43-year-old man, who worked as a sand extractor in river benches, was admitted to the Emergency Department, presenting with paraparesis and urinary retention. He had previously sought medical care due to fever and headache four days earlier.
Both cranial and thoracolumbar computerized tomography scan were normal. Cerebrospinal fluid (CSF) revealed the following: Glucose <20mg/dL, 96 white blood cells/mm³ (WBC) - 75% lymphocytes, protein 536mg/dL, negative nucleic acid amplification test (NAAT) for tuberculosis (TB), negative Ziehl–Neelsen staining and negative direct microscopy for acid-fast bacilli. Extra neural sites of TB disease were excluded after screening exams as well as neoplastic, inflammatory and other infectious diseases, including HIV.
Magnetic resonance imaging was performed and revealed thick diffuse leptomeningeal enhancement, ischemic infarcts in basal ganglia, obstructive hydrocephalus and longitudinal extensive transverse myelitis, from T8 to T11.
Due to high suspicion, standard anti-tuberculous therapy was prescribed for presumed TB. During treatment, six CSF samples were collected, showing progressive decrease of Glucose, protein and WBC levels. NAAT, direct microscopy and staining were negative in all samples.
Despite medical assistance, patient died seven weeks after symptoms onset. Two weeks after his death, Mycobacterium tuberculosis was detected in CSF cultures.

Discussion

Central nervous system (CNS) involvement is considered one of the most severe manifestations of extra-pulmonary TB. Immunosuppression is an important risk factor. For instance, HIV/AIDS patients have a five-fold increase in the likelihood of having CNS involvement. Despite being highly sensitive and specific, negative NAAT or any other test should not exclude the diagnosis.
The present case report is relevant because the rapid TB test, NAAT, which is meant to speed up diagnosis and to guide a better clinical approach, was, in six samples, negative, despite the high suspicious for mycobacterium disease.

Conclusion

Definitive diagnosis of CNS TB is difficult and may take weeks. This case shows the importance of valuing all the clinical conditions that suggest neurotuberculosis when approaching a patient.
Despite the availability of modern and rapid molecular tests, diagnosis should not rely solely on them, and treatment should not be postponed.

Palavras Chave

neurotuberculosis, Cerebrospinal fluid