Postgraduate Medical Journal | 2021
Extensive intracranial tuberculosis
Abstract
© Author(s) (or their employer(s)) 2021. No commercial reuse. See rights and permissions. Published by BMJ. DESCRIPTION A 20yearold woman presented with a history of lowgrade fever, headache and progressive diminution of vision for 2 months. She appeared drowsy, and on examination, neck rigidity and Kernig’s sign were positive. The patient’s relatives did not give any history of cough, shortness of breath, night sweats or contact with a known case of tuberculosis. Visual acuity at the time of admission was reduced to perception of hand movements close to the face in the right eye and 6/60 in the left eye. Cerebrospinal fluid (CSF) examination revealed normal opening pressure with lymphocytic pleocytosis, markedly elevated protein and low glucose levels. CSF GeneXpert assay was negative and CSF adenosine deaminase levels were increased. MRI of the brain showed multiple ringenhancing lesions in bilateral cerebral hemispheres, basal ganglia, cerebellum and dorsolumbar spine (figure 1A). Similar lesions were seen in bilateral optic nerves along with the evidence of opticochiasmatic arachnoiditis (figure 1B). Considering the endemicity of tuberculosis in the region and the typical radiological picture, a diagnosis of central nervous system (CNS) tuberculosis was made. Other differential diagnoses considered were neurocysticercosis, CNS toxoplasmosis, cryptococcal meningitis and CNS lymphoma. After ruling out these differentials based on relevant CSF and serum analysis (with a negative HIV serology, CSF cryptococcal latex agglutination test, and toxoplasma serology), the patient was started on weightbased antitubercular therapy and steroids. Steroids were administered in form of pulse methylprednisolone (250 mg for 3 days), as the literature review revealed improvement in opticochiasmatic arachnoiditis following such therapy. Over the next 2 weeks, her sensorium gradually improved and she was discharged with advice to followup in an infectious disease clinic. On followup visit at four months, her symptoms improved but visual impairment persisted and she required assistance with activities of daily living.