Case Presentation
A 25-year-old female with no known comorbidities presented with complaints of fever, productive cough, generalized body weakness, vomiting, and anorexia for five months. However, she gave no history of evening rise in temperature, significant weight loss, blood in sputum, or contact with TB-positive people. Physical examination, including vitals and general and systemic examination was normal.
Chest X-ray showed miliary nodules in bilateral lung fields, while gene Xpert sputum test revealed rifampicin-sensitive Mycobacterium tuberculosis. Pulmonary tuberculosis was thus diagnosed on the grounds of a positive gene Xpert test and features of tuberculosis in a chest radiograph. Antitubercular therapy (ATT) with rifampicin, isoniazid, pyrazinamide and ethambutol was started. However, as she developed increased oxygen requirements, she was admitted to the medical ICU. During ICU stay, the patient developed irrelevant talking, altered mental status, and increased shortness of breath. She also had an episode of a generalized tonic-clonic seizure. Following this, a lumbar puncture was done, which showed lymphocyte predominance, increased protein, and decreased glucose level. However, adenosine deaminase (ADA) was within normal range, and acid-fast bacillus was not seen. Thus, TB meningitis was diagnosed on the background of pulmonary tuberculosis.
The patient was referred to our center five days after starting ATT for better management. At the time of presentation, her vitals showed blood pressure of 135/70 mmHg, pulse rate of 82 bpm, temperature of 36 C, respiratory rate of 20 breaths per minute, and oxygen saturation of 100% in 15 liters per minute of oxygen. On auscultation of the chest, decreased air entry and crepitations were heard in bilateral lung fields. The patient had spontaneous eye opening, inappropriate vocalization, and localizing movement with pain (E4V3M5). Motor examination revealed power of 4/5 in bilateral upper and lower extremities, normal tone and deep tendon reflexes in bilateral upper limbs and lower limbs, normal plantar reflex, and intact sensation. Neck rigidity was present while Brudzinki’s and Kernig’s signs were absent.
Lab investigations showed increased liver enzymes; AST: 78 U/L, ALT: 80 U/L, GGT: 95 U/L, increased CRP (73 mg/L), methicillin-sensitive coagulase-negative Staphylococcus in blood culture, Na- 133mmol/Lt, K-3.6 mmol/Lt, Hb-11.5 g/dl, total leukocyte count of 9489 / cubic mm. Serology of HCV antibody, HBsAg, HIV 1 and 2 antibodies was negative. In the NCCT head, mild effacement of sulcal spaces in bilateral cerebral hemispheres was seen. FLAIR imaging showed features suggestive of hydrocephalus. (Figure 1) MRI of coronal section of brain showed multiple enhancing nodular lesions in bilateral hemispheres. (Figure 2) A high-resolution CT scan of the chest showed mild pneumomediastinum, numerous randomly distributed miliary nodules in bilateral lungs, patchy areas of consolidation, and few patches of ground glass opacities in bilateral lower lobes. Based on findings of LP, MRI head, HRCT chest, and gene Xpert test, the final diagnosis of disseminated tuberculosis was made.