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.