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Título

RECURRENT NEUROTUBERCULOSIS WITH RIFAMPICIN RESISTANCE IN IMMUNOCOMPETENT PATIENT: A CASE REPORT

RESUMO

CASE PRESENTATION: Male, 38 years old, previously healthy, in 2018, presented progressive headache, vomiting and fever. After 4 months, diplopia and syncope. On exam, generalized lymphadenomegaly and vertical conjugate gaze limited. Viral hepatitis, syphilis and HIV serologic tests were negative. Cerebrospinal fluid (CSF) showed inflammatory pattern with increased opening pressure, and immunological tests to syphilis, cytomegalovirus, Epstein-Barr, cultures for fungi and mycobacteria were negative. Brain MRI showed solid hypointense nodular images, enhancement in the frontal and bilateral temporal regions. Lung and brain biopsies were inconclusive. Empirical treatment for tuberculous, fungal meningoencephalitis, nocardiosis, and pyogenic brain abscess was started. Antituberculosis drugs were used for 12 months and maintenance doses of fluconazole and prednisone, with improvement of diplopia and headache. After 2-years, he presented again with pain and right axillary lymph node enlargement, anatomopathology realized, suggested ganglionar tuberculosis, and no other changes in new radiological exams. The rapid molecular test for tuberculosis (TRM-TB) was positive with no resistance to Rifampicin and antituberculosis drugs and corticotherapy was reinitiated. Primary immunodeficiencies were searched, with no abnormalities. At the end of treatment, corticotherapy was discontinued; however, diplopia, visual blurriness, dizziness, and headache returned. New brain MRI showed active mesencephalic lesions and MRI-BT of a CSF sample positive for rifampicin resistance. Then, alternative regimen for rifampicin-resistant neurotuberculosis with RIPE regimen, Levofloxacin and Clarythromicin, and adjustment of prednisone were chosen, with improvement of symptoms and outpatient follow-up. DISCUSSION: Central nervous system tuberculosis is an infrequent extrapulmonary manifestation. Prior to antituberculostatic therapy, this condition was uniformly fatal and still results in high morbidity and mortality today. The main risk factors are associated with compromised immune system; therefore, its occurrence in immunocompetent patients is rare. High clinical suspicion and early treatment are associated with better outcomes. FINAL COMMENTS: Neurotuberculosis remains a challenge diagnostic, especially, in immunocompetent patients, the high sensitivity and specificity of diagnostic tests are important tools, however, in some cases, it remains a diagnostic and therapeutic challenge.

Palavras Chave

NEUROTUBERCULOSIS. RIFAMPICIN RESISTANCE. IMMUNOCOMPETENT.