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ATYPICAL NEUROTUBERCULOSIS IN AN ADOLESCENT WITH CLINICAL PRESENTATION OF MENINGOENCEPHALOMYELITIS FORM: A CASE REPORT

RESUMO

CASE PRESENTATION: A previously helalthy, 17-year-old woman, with a complete vaccination schedule, in april 2021, presented acute onset of moderate-intensity headache evolving after 2 days to reduced consciousness. Neurological exam: regular general condition, drowsy, uncooperative, and contacting. Presence of meningeal irritation. Ophthalmoplegia in left eye abduction and right eye with nystagmoid jerks. Right central facial. Right hypotonia and left elastic hypertonia (Ashworth-2). Muscle strength-MRC-2, bilateral. Hypoactive deep reflexes globally, bilateral Babinski. Empirical treatment was instituted immediately for bacterial, viral meningoencephalitis, corticosteroid, and therapy for neurotuberculosis. Rheumatological tests and serum angiotensin-converting enzyme negatives. Cerebrospinal fluid (pleocytosis-lymphomononuclear, hyperproteinorrachy and hypoglycorrhachia), negative results to gram, fungus culture and tuberculosis genexpert. Brain MRI with hypersignal of left nucleus-capsular; thickening and enhancement of supra and infratentorial meningeal planes; prominent supratentorial ventricles; focal nodular with peripheral enhancement in right insula. Cervicothoracic and lumbosacral MRI revealed thickening and enhancement of posterior leptomeningeal in D2 and D8; hypersignal D4 to D7 (edema), left enhancement of descending nerve root of S1(inflammatory neuropathy); increased dimensions and leptomeningeal nodular foci enhancement in C7 and D11 segments. Normal transesophageal echocardiogram. Subsequently, COXCIP drug-induced hepatitis with suspension, and an alternative tuberculostatic RIPE regimen was replaced, being reintroduced drug by drug each month, for 12 months. The patient presented motor improvement (MRC-4) after 6 months. Maintain outpatient follow-up, with motor rehabilitation. DISCUSSION: Central Nervous System Tuberculosis is 1% of all tuberculosis cases and half of these involve the spine. Intramedullary involvement is rare, usually expressed in radiculomyelitis, transverse myelitis, intraspinal granulomas, or anterior spinal artery thrombosis. PCR test for M. Tuberculosis has sensitivity from 56% to 90% and specificity from 88% to 100%. FINAL COMMENTS: As already documented and supported by case series, it is essential, especially in endemic areas, to consider causes of infectious mycobacterial etiology, particularly tuberculosis, in the differential diagnosis of radiculomyelitis, even if the etiological evidence is not confirmed.

Palavras Chave

Tuberculosis;encephalomyeloradiculitis; meningoencephalomyelitis