Clinical Medicine and Health Research Journal (CMHRJ)

Volume 03, Issue 03, May - June, 2023

Page No. 389-391

Case Report

Severe Tuberculous Meningitis with Fatal Consequences in a Pediatric

Patient: A Case Report
Abdul Khalid Qadree1, Sachin Mahendrakumar Chaudhary2, Anasonye Emmanuel Kelechi3*,
Sushmita Pandey4, Sandesh Dhakal5
1
Department of Pathology, Caribbean Medical University Willemstad Curaçao PIN code: 4797
2
Department of Internal Medicine, SMT. NHL Municipal Medical College Ahmedabad Gujarat, India
3
Department of Pathology, Texila American University Guyana Carribean
4
Department of Neurology, Nepal Medical College Jorpati Kathmandu Nepal
5
Department of Neurology, College of Medical Sciences Bharatpur Nepal PIN code: 44207

Received: 05 April, 2023 Accepted: 04 May, 2023 Published: 09 May 2023

Abstract:
Background: Tuberculous meningitis is a critical public health issue in underdeveloped nations due to its high morbidity and
death. Tuberculous meningitis with non-specific symptoms of the central nervous system in children needs to be assessed with
great vigilance as delay in diagnosis results in poor prognosis.
Case Report: We present a case of 20 months old female child with symptoms of sensory alteration, aberrant movements, and
fever. Lumbar puncture findings indicated cell count of 1121/mm3, reduced glucose level, and elevated proteins.
Ventriculomegaly with diffuse hypodenseimages in the frontal and paraventricular regions with areas of ischemia and
hydrocephalus were evident in the MRI. Neuroinfection was indicated with images compatible with obstructive hydrocephalus of
early evolution suggestive of tuberculous meningitis. The patient was started on 2HRZE/10 hr regimen. However, the patient was
observed with significant neurological sequel and presented multiple comorbidities despite supportive measures.
Conclusion : Children are more susceptible to tuberculous meningitis than adults and result in death and disability, if not
diagnosed early. Hence, the physicians must always be on the alert for tuberculous meningitis, especially in the areas where
tuberculosis is endemic

Keywords: Tuberculous meningitis, obstructive hydrocephalus, motor deficit, panarteritis, thrombosis.

1. Introduction:
The most severe form of pediatric tuberculosis (TB), A 20-month-old female child, who had previously been
tuberculous meningitis (TM), has a significant fatality and healthy, presented to the emergency room with a five-day
morbidity rate [1]. Children, their families, and healthcare history of persistent vomiting, a fever measuring 38.5, and
systems must deal with serious long-term implications of the brief clonic movements of the upper and lower extremities,
neurological dysfunction caused by TBM, hence prevention followed by a period of lethargy without regaining her regular
and early diagnosis are crucial [2]. 12% of the estimated level of consciousness. Examining the mucous membranes
worldwide TB burden is accounted for by children under the revealed paleness, varying times of irritation and sluggishness,
age of 15 [3]. High risk groups for TB and TB-related symptoms of dehydration, cervical lateralization to the right,
mortality include people under the age of five and people stiffness in the neck, isochoric pupils, photoreactive,
living with HIV [2, 4]. This places TB as one of the top 10 retroauricular adenopathies, and retained muscle tone. There
causes of under-5 death. Disseminated TB, especially TBM, is were reflexes, ventilated lung fields, normal phonetic heart
worrisome for children under the age of two. TBM is sounds, no peritoneal irritation in the belly, and limbs that
devastating without treatment [1], and undetected cases or were still mobile but had lost strength, scoring a 4/5 on the
those diagnosed late probably contribute significantly to muscle strength scale. The preliminary findings indicated
juvenile TB mortality worldwide. This case presentation normal leukocytes, hypochromic microcytic anaemia,
intends to draw attention to the typical TBM presentation, thrombocytosis, increased c-reactive protein, hyperglycemia,
imaging results, and diagnostic difficulties. normal serum electrolytes, and a normal general urinalysis in
the biometry. The diagnosis of neuroinfection was made given
2. Case Presentation the symptoms of sensory alteration, aberrant movements, and

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fever. During lumbar puncture, xanthochromic fluid with a HIV infection, immunosuppression, and chronic illness.
cloudy appearance, a cell count of 1121/mm3, primarily Through hematogenous dissemination, the bacilli enter the
monocytic, a glucose level of 26 mg/dl, and high proteins of central nervous system, form granulomas, and then combine to
1181 g/dl were found. CSF was negative for AFB, CSF gram create Rich's caseous foci, which can rupture the subarachnoid
without microorganisms, and the CSF culture was negative for space and cause meningitis [3]. Children are more susceptible
bacterial growth. Pandy's reaction was positive, than adults to developing TBM from primary TB. Stage III of
Using a standard skull tomography, it was evident that the the illness, a deep coma, and young age are the greatest risk
patient had ventriculomegaly with the presence of diffuse factors for a bad prognosis, including fatality. Cerebrospinal
hypodense images in the frontal and paraventricular regions, fluid proteins above 100 mg/dl, hypertonia, delayed
as well as areas of ischemia and hydrocephalus (Fig.1). hydrocephalus care, the existence of strokes, a focal deficit at
Further investigations indicated non-reactive HIV test, admission, cranial nerve palsy, and seizures are other factors
negative toxoplasma, cytomegalovirus and rubella, that have been observed, though not consistently in most
immunoglobulin dosage and normal compliment. An series [4]. Inflammatory exudates, one of the most important
assessment by the neurology department indicated a features in the pathogenesis of meningitis, involves the basal
neuroinfection with images compatible with obstructive blood vessels of the brain and generates a panarteritis that
hydrocephalus of early evolution suggestive of TBM and MRI results in occlusion and thrombosis of the blood vessels [3].
was requested. Contact history is important for the diagnosis of TB. Wu and
In multidisciplinary criteria, pediatrics, neurology, and colleagues suggested that household contact has a higher risk
infectious diseases indicated a diagnosis of TBM based on of severe TB, with a reported rate of 31% [5]. According to
epidemiological criteria and imaging. The 2HRZE/10 hr some researchers, the prognosis is associated with CT
regimen was started with prednisolone at 2mg/kg/day for 4 findings, particularly at the time of diagnosis; nevertheless,
weeks. During her hospital stay, the patient was observed with some secondary problems that arise after the diagnosis may
significant neurological sequel, received phenytoin as have a detrimental impact on the prognosis. The most frequent
anticonvulsant support, presented multiple comorbidities secondary issue in TBM is hydrocephalus, which has a poor
despite supportive measures, including placement of prognosis and is linked to persistent impairment [5]. The
ventricular peritoneal shunt valve and antireflux technique, intracranial findings in our case agreed with previous research.
with torpid evolution. Mycobacteria found in CSF provide the basis for the
conclusive diagnosis of TBM. In adults, the diagnostic yield of
culture ranges from 37-87%, whereas in children, it is just 15-
20% [6]. When the CSF volume is larger than 5 ml [7], the
sample quality is good, the likelihood of isolating bacilli
improves. In our case, acid resistant bacillus (ARB) was
negative at the initial CSF evaluation, also ARB positivity
could not be established in the CSF in serial lumbar punctures.
This can be explained by the presence of small number of
bacilli and/or technical deficiencies [7]. Due to the spinal
canal obstruction, the CSF protein levels in TBM patients are
elevated [6] and protein levels of >2g/l suggested a greater
possibility of TBM. The patient in our case had CSF protein
level of 11.81 g/l, thereby indicating a greater possibility of
TBM. The reduced glucose levels (26mg/dl) in our case were
similar to the findings of previous studies.
Clinically, the management of TBM typically entails anti-TB
medication in addition to symptomatic and supportive care. In
Figure 1: Skull tomography showing evidence of children with moderate to severe TBM, Schoeman et al [5]
ventriculomegaly with the presence of diffuse hypodense examined the impact of high dosages of predinsolone on
images in the frontal and paraventricular region, with areas of intracranial pressure changes, imaging results, and clinical
ischemia and hydrocephalus. outcomes. It was shown that patients who received steroids
had higher survival rates and improved mental abilities. It is
3. Discussion
debatable whether corticosteroids should be used as adjuvant
The most severe extrapulmonary form of Mycobacterium therapy in TBM. According to the majority of the studies,
tuberculosis infection, TBM, is a critical public health issue in TBM patients using steroids have better neurological and
underdeveloped nations due to its high morbidity and death, survival results [7].
despite the availability of contemporary treatments. Children
with untreated extrapulmonary TB have a 1% to 2% chance of
4. Conclusion
developing meningitis [1]. The risk factors that encourage To minimize death and disability, it is essential that TBM in
progression include infancy, malnutrition, measles infection, children is diagnosed early. Children with TBM may have

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Clinical Medicine and Health Research Journal, (CMHRJ)
vague symptoms, and the usual neck stiffness is frequently control strategies. Clin Infect Dis. 2009: 1;48(1):108-14.
absent in the early stages of the disease. Hence, healthcare doi: 10.1086/595012. PMID: 19049436.
professionals must always be on the alert for TBM, especially 2. Vadivelu S, Effendi S, Starke JR, Luerssen TG, Jea A. A
in areas where TB is endemic. Therefore, the diagnosis is review of the neurological and neurosurgical implications
primarily clinical and is based on a combination of the clinical of tuberculosis in children. Clin Pediatr (Phila). 2013:
history, physical examinations, CSF characteristics (typically 52(12):1135-43. doi: 10.1177/0009922813493833. Epub
clear appearance, moderately raised white cell count, 2013 Jul 10. PMID: 23847176.
lymphocyte predominance, elevated protein level, and 3. Drevets DA, Leenen PJ, Greenfield RA. Invasion of the
hypoglycorrhachia), and neuroimaging that showed basal central nervous system by intracellular bacteria. Clin
meningeal enhancement, infarction, hydrocephalus, and/or Microbiol Rev. 2004:17(2):323-47. doi:
tuberculomas. 10.1128/CMR.17.2.323-347.2004. PMID: 15084504;
PMCID: PMC387409.
Declarations
4. Garg RK. Tuberculous meningitis. Acta Neurol
Patient’s consent Scand.122(2):75-90. doi: 10.1111/j.1600-
Informed consent was obtained from the patient for the 0404.2009.01316.x. Epub 2010 . PMID: 20055767.
publication of this case. 5. Wu XR, Yin QQ, Jiao AX, Xu BP, Sun L, Jiao WW, Xiao
J, Miao Q, Shen C, Liu F, Shen D, Shen A. Pediatric
Funding statement tuberculosis at Beijing Children's Hospital: 2002-2010.
This research did not receive any specific grant from funding Pediatrics. 2012: 130(6):e1433-40. doi:
agencies in the public, commercial, or not-for-profit sectors. 10.1542/peds.2011-3742. Epub 2012 Nov 26. PMID:
23184116.
Authorship 6. Swaminathan S, Rekha B. Pediatric tuberculosis: global
All authors had access to the data and a role in writing this overview and challenges. Clin Infect Dis. 2010: 15;50
manuscript. Suppl 3:S184-94. doi: 10.1086/651490. PMID: 20397947.
7. Thwaites GE, Chau TT, Farrar JJ . Improving the
Declaration of competing interest bacteriological diagnosis of tuberculous meningitis. J Clin
None Microbiol. 2004 42(1):378-9. doi: 10.1128/JCM.42.1.378-
379.2004. PMID: 14715783; PMCID: PMC321694.
Acknowledgements
None to declare Copyright (c) 2023 The copyright to the submitted
manuscript is held by the Author, who grants the Clinical
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