A three–year–old male was transferred to our tertiary care facility with a one week history of vomiting and decreased activity and ongoing worsening mental status after admission to a community hospital for dehydration. A head computed tomography (CT) scan revealed possible enlargement of the third ventricle and a lumbar puncture showed pleocytosis (WBC 57 with 60% lymphocytes, glucose 19, protein 49). Initial laboratory evaluation included cerebrospinal fluid (CSF) studies for viral agents. bacterial, fungal , acid–fast bacilli (AFB), and viral cultures and serologic tests for viral pathogens. Empiric broad spectrum antibiotics and acyclovir were initiated. Imaging with Magnetic Resonance Imaging (MRI) revealed left lepto–meningeal enhancement consistent with meningitis, communicating hydrocephalus, and fluid in the middle ear and mastoid sinus consistent with mastoiditis. An extra–ventricular drain was placed, but patient had ongoing hydrocephalus on the subsequent imaging, the development of a unilateral oculomotor nerve palsy, and continued worsening of his mental status. As bacterial and viral cultures remained negative, and the patient was not improving, a T–SPOT.TB test was ordered and a (Purified Protein Derivative) PPD skin test was placed. The PPD had 18 mm induration and T–SPOT.TB was positive. An exhaustive history for possible TB exposures revealed no concerns initially, but after diagnosis and contact investigation, the patient’s great–grandmother was determined to be the source of infection. An appropriate anti–TB regimen was initiated including pyrazinamide , rifampin, isoniazid, and ethambutol, and dexamethasone was started. Otorhinolaryngology placed a tympanostomy tube, and the fluid from the middle ear was determined to be tuberculous. The patient had been recently treated for otitis media and was scheduled for outpatient tympanostomy tube placement due to chronic otitis media. Immune workup revealed no abnormalities. The patient showed steady improvement with ongoing left–sided weakness and difficulties with speech and feeding. He was transferred for inpatient rehabilitation after about 3 weeks.
TB meningitis remains an unusual cause of meningitis in children in the United States. There have been few reports of TB otomastoiditis occurring with meningitis in children, however some studies suggest that the incidence of radiographic evidence of otomastoiditis seen with TB meningitis may be as high as 34%. The causal relationship between TB otomastoiditis and meningitis remains somewhat unclear, but we consider that the otomastoditis could have been the likely source of infection in this patient.
This case highlights the need to maintain a high index of suspicion for tuberculosis in patients with chronic otomastoiditis that does not respond to conventional treatment. Rapid diagnosis and early treatment are crucial for the outcome of TB meningitis.