RARE APRESENTATION OF TUBERCULOUS MENINGITIS: A CASE REPORT

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INTRODUCTION
Tuberculosis infections, regardless of clinical presentation, are established with the inhalation of bacilli into distal airways, in the form of droplet nuclei. After escaping from the airspace into the interstitium, M. tuberculosis spreads first to the local draining lymph nodes in the lung and then to distant sites via the bloodstream. Tuberculous meningitis is the most devastating manifestation of infection with Mycobacterium tuberculosis and represents a medical emergency. Approximately one half of tuberculous meningitis patients die or suffer severe neurologic disability.M. tuberculosis infections of the central nervous system most commonly present as subacute or chronic meningitis. There may also be discrete granulomas (tuberculomas), and these lesions may enlarge or coalesce sufficiently to present with the signs and symptoms of space-occupying lesions.
CASE REPORT
A 26-year-old female patient was referred by the Emergency Care Unit (UPA), where she was hospitalized for 4 days. The patient presented a clinical picture of headache, mental confusion, nausea, emesis and alternating drowsiness with agitation for more than 60 days. Thirty days ago, the condition developed, with worsening mental confusion, impaired concentration and temporo-spatial disorientation. She also reported febrile illness with onset 8 days ago. As reported by the patient, 11 months ago she presented "viral meningitis", associated with herpes zoster, being medicated with acyclovir and corticosteroids. On physical examination, a globular abdomen was observed, painful to the superficial palpation diffusely, with palpable mass in the left hypochondrium. Neurological examination found consciousness level fluctuation, mental confusion, no signs of meningeal irritation and scored 14 on the Glasgow scale.
DISCUSSION AND CONCLUSION
From the results of the physical and neurological examination, some laboratory and imaging tests were requested. In the complete blood count done on February 24th, 2009, there was a decrease in the leukocyte level, presenting a value of 1900/mm3 (reference value: 3000 - 10000/mm3). On the same day, cerebrospinal fluid (CSF) was analyzed, which, in turn, although the physical characteristics corresponded to the normal aspect, the latter presented high leukocyte cellularity, corresponding to 61 p/mm3 (reference value: 0-5 p/mm3). In addition, protein levels were also altered, corresponding to 216.81 mg/dL (reference values: 20-40 mg/dL). Laboratory analysis of CSF allows the collection of important information; the increase in the number of leukocytes is called pleocytosis and may be related to an inflammatory process in the cerebrospinal fluid.
For a better analysis of the case, Magnetic Resonance (MRI) of the sellaturcica and Computed Tomography (CT) of the skull with contrast, chest and abdomen were requested. Sellaturcica MRI showed thickening and alteration of the prechassis signal of optic nerves, optic chiasm and hypothalamus, associated with nodulariformleptomeningeal enhancement, as well as signal and nodulariform enhancement on the surface of the III ventricle and the frontal horns of the lateral ventricles and on the leptomeningeal surface in the cisterns of the base, among other characteristics. The MRI analysis includes as differential diagnosis the possibility of an infectious inflammatory process.
The cranial CT revealed presence of nodular heterogeneous enhancement of the meningeal contours of the skull base, cisterns, some cortical grooves, scythe and cerebellum tent. Chest CT revealed the presence of multiple mediastinal lymph node metastases, some conglomerate, para-aortic, in the aorto-pulmonary, subcranial windows, with the largest ones measuring about 3 cm. Bilateral axillary lymph node enlargement was also observed. CT scan of the abdomen showed multiple adenomegalies in the cervical, retroperitoneal and inguinal regions, measuring about 10 cm each. A lymph node biopsy was requested due to the finding of lymph node enlargement. An inguinal lymph node was used as the material for the biopsy. The biopsy concluded a chronic granulomatous lymphadenitis with necrosis compatible with tuberculosis, and the search for BAAR using the Faraco method was positive.Therefore, the patient in question was diagnosed with meningeal tuberculosis, without involvement of other systems, that is, only with presentation in the central nervous system.
As a treatment for meningeal tuberculosis, the recently updated guidelines of the American Thoracic Society, Infectious Disease Society of America and the US Centers for Disease Control and Prevention recommend the initial four-drug therapy: isoniazid, rifampicin, pyrazinamide, and ethambutol due to good penetration and concentration in the CSF.