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Tuberculous meningoencephalitis

Article  in  Medical Archives · January 2010

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 Tuberculous meningoencephalitis

Tuberculous meningoencephalitis
Sefedin Muçaj 1,3, Shemsedin Dreshaj 2,3, Serbeze Kabashi3, Hajrije Hundozi3, Sanije Gashi 1,3,
Valbona Zhjeqi 1,3, Nexhmedin Shala3, Manushaqe Kryeziu3
National Institute of Public Health of Kosova, Pristine, Republic of Kosova1
Infectious clinics, UCCK, Pristine, Republic of Kosova2
Faculty of Medicine, Pristine University, Pristine, Republic of Kosova3

CASE REPORT
SUMMARY
Tuberculous meningitis is an infection of the the
membranes covering the brain and spinal cord (me-
ninges). Tuberculous meningitis is a major global
health problem and is the most severe form of ex-
trapulmonary tuberculosis, with high rate mortality.
Last years in Kosovo incidence of TB was decreased
in less than 1000 cases per year and 10-20 cases
per year of TB meningoencephalitis. Still Kosovo
Corresponding author: Ass. Dr. Sefedin Muçaj, MD, PHD, National Institute of Public Health of Kosova, Pristine
sefa66@gmail.com; mob tel. +377 44 223 782
has limited numbers of TB. TBM is diagnosed on the
basis of clinical features, cerebrospinal fluid (CSF)
studies, and radiological findings. Clinical picture,
neurological status, anamnestic data, suspect (but
not specific) lab tests, and imaging new methods,
together can give very valuable help to clinicians for
early adequate and successful treatment.
Key words: tuberculous meningoencephalitis, early
diagnosis, radiological images (MRI)
of TBM can save lives and probably re-
duce neurological deficits; therefore, a
sensitive and specific early diagnostic
test is urgently required (5).
Usually, high fever and severe head-
ache is observed. After, nausea and
vomit are followed. If these symptoms
and objective symptoms (neck stiff-
ness, Kernig sign and Lasegue sign)
are observed, Computer Tomography
is applied and Lumbar puncture will
be executed if there is no sign of brain
edema. Only rapidly started treatment

Name and Surname: R.C.

Birth place: Dardania- Prizren
1. INTRODUCTION 2. CASE PRE- DOB: 1980
Tuberculous meningoencephalitis SENTATION Hospitalization: 02.02.2009–05.04.2009
Discharge diagnosis:
(TBM) is a rarely diagnosed form of tu- In Table 1 and Meningonecephalitis TBC

berculosis. It is characterised with high (Figure 1 and 2) Main complains: headache, vomiting, fever >38oC

mortality (1). In the past several years
there has been a global increase in the
incidence of tuberculosis among with
the prevalence of AIDS and the emer-
gence of multidrug-resistant strains[
(2). Tuberculous meningitis is a major
global health problem and is the most
severe form of extrapulmonary tuber-
culosis, with high rate mortality (3).
Last years in Kosovo incidence of TB
was decreased in less than 1000 cases
per year and 10-20 cases per year of TB
meningoencephalitis. Still Kosovo has
limited numbers of TB. In eastern Eu-
rope the incidence of TB is in increas-
ing, also TB meningitis, partially in im-
munocompromised patients.
The increased morbidity of tubercu-
below is presented Anamnesis data: Patient is treated ambulatory for 7 days without improvement. During last he
become unconscious and in the admitions become severely ill.
patient: R.C., 1980, In admition:
Prizren with clini- -feverish, disoriented, unconcisious, without possibility for verbal contact.
cal data and radio- -in meningeal position.
-Pulmo: in auscultation normal,
logical images and -Meningeal syndrome: complete positive.
-Neurological status: Central facial right palsy, absent cutaneoabdominal reflexes , clonus patellae
treatment of the for 10” and babinsi positive on the left.
patient in Infec- During hospitalization after 6 day pt. become afebril, concisiouns, and the neurological defects
disappears. The same treatment was continued till discharge.
tious clinics, Uni-
Anla. Lab.: ESR=21/, Erc=3,3, HB=12.2, WBC=8.000, N=80, M=20%, urina:alb+, sed= 12-15 Le,
versit y Clinical 4-5 erc. urea=12.0...12.6...14.6....5.0 ; kreatina= 100...87...103 glikemia= 6.7; ...6.28...4.95...4.75,
CSF analysis: L.P. CSF hypertonic, with normal color, with pelocitosis = 80, Monocytes = 100%;
Centre of Kosova, glikorrakia = 1.0, proteinorakia = 0.504g/L; CT cerberi normal, Sinus x-ray = normal, Chest X ray
Pristine. normal, Ophtalmologic exam normal. ENT normal.
In the next days was done Mantoux that show positive reaction (20 mm), and Hexagon TB test
which was also positive.
CSF exam for BK was negative and also the Culture of Loevenstein was negative.
3. DISCUSSION Later CSF analysis present hypoglicorakia, high proteins and intermittent pleocytosis.
The diagnosis In discharge: ESR=4/ Erc=3.8, HB=12.2; WBC=4.4 (N=68, M=2, E=2, L=28), Bil. Tot=24.0
(normal); AST=14, ALT=24; urea=4.5; kreatinina=81, glikemia=5.28; CSF= normotonic, 32 WBC,
of TBM is difficult Mono=100%, glikorrakia=2.72 (normal); proteins=0.48 g/L(elevated). Chest X ray= enlarged
lymph nodes in both sides of the lung. (Adenitis bill pulmonum).
because the clin-
From the beganing tretmant was with Manitol 20%, Dexamthasone 0.15 mg/Kg/per dosis
ical features are every 6 h, four antituberculous drugs, Phenobarbiton 100 mg per 24 h, and other symptomatic
nonspecific and medication.

losis in recent years makes it necessary
to consider this etiology in the diagno-
sis of CNS infections especially with se-
vere atypical and long lasting course (4).
In the case when tuberculous etiology
is suspected the anti tuberculous treat-
ment should be applied.
the CSF may con- In admition was done CT scan of the brain where was presented dilated ventricular system.
Because the clinical outcome become unclear and patient become worsened was recommend
tain so few bacilli to do the MRI where was presented enhancement with contrast. This was suspect for basal
meningitis which was the first sign to orient the diagnosis for TB examination.
that they are nei-
Conclusion: Based Citobiochemical analysis, intermittent pelocytosis, Mantoux reaction, Hexagon
ther seen nor cul- TB test, MRI, and effect of antituberculous medicines in successful treatment of the patient we
conclude that patient has TB meningitis.
tured. However,
the early diagno- Table 1. Discharge List for patient examined in Infectious clinics, University
Cilnical Center of Kosova, Prishtine
sis and treatment

MED ARH 2010; 64(3) • Case report 189

and to the increasing incidence of tuberculous among infants, children, and young ad
Tuberculous meningoencephalitis


4.  CONCLUSION

As long as   and
tuberculosis 
extra- 
pulmonary tuberculous continues to

flourish in developing countries, tu-
 meningoencephalitis
berculous  
will re- 

main  
a constant threat throughout the 
world. Because the early diagnosis is

very difficult in the beginning and the
key to a satisfactory outcome, a high

level is essential.
of suspicion     
Clinical
picture, neurological status, anamnes-
   
tic data, suspect (but not specific) lab

tests, to- 
and imaging new methods,

gether can give very valuable help to
Figure 1 and 2. MRI. (1) Axial T1 C+MR shows diffuse, basilar enhancement in this patient with clinicians for early adequate and suc-
tuberculous meningitis. The basal predominance can help differentiate TB from other causes of cessful treatment.
meningitis. (2) Axial CT in the patient shows nonenhancing diffuse white matter hypodensity frontal right
and ventriculomegaly.
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