Case Presentation: A 35-year-old French-speaking man with no known medical history presented with a 3-week history of worsening abdominal pain and waxing and waning headache associated with photophobia and phonophobia. He had two prior emergency department visits for similar symptoms and was empirically treated for migraines after normal head imaging. He also endorsed moderate abdominal pain associated with nausea and vomiting over the prior 3 days, and intermittent subjective fevers over the previous two weeks. Additional history was confounded by a language barrier; the patient spoke a regional dialect of French that was not readily understood by interpreter services. Furthermore, collateral obtained from his family identified important symptoms: altered mental status and new left hemiparesis. Subsequently, a CT head revealed a new right internal capsule infarct. CT of the abdomen and pelvis demonstrated an incidental pleural-based lesion, later confirmed on chest CT as well as pneumomediastinum, MRI of the head revealed leptomeningeal enhancement with multiple acute and subacute infarcts of the right cerebrum and cerebellum. Additional work-up revealed positive Quantiferon Gold, and lumbar puncture with lab values suggestive of mycobacterial infection. Empiric treatment was started for tuberculosis meningitis. Pathology from the pleural mass was consistent with granulomatous disease with a positive MTB PCR. His course was complicated by intracranial inflammatory treatment reaction attributed to paradoxical IRIS that responded well to corticosteroid treatment prior to recovery and discharge home.
Discussion: Here we present a case of extrapulmonary tuberculosis manifesting as meningitis and a seemingly unconnected isolated pleural mass. His lack of pulmonary symptoms, initially normal head imaging, and the presence of a solitary pleural mass, typically associated with an effusion, did not suggest tuberculosis as a unifying diagnosis. Further evaluation, including recognition of a new stroke, was hindered by a language barrier that was only resolved through collateral history obtained from family members. Appropriate treatment was initiated only after cerebrospinal fluid studies indicated a mycobacterial infection. Because tuberculous meningitis often evolves in distinct stages and commonly begins with a subacute presentation, diagnostic and treatment delays are frequent and contribute to substantial morbidity and mortality. This case underscores the importance of persistently seeking collateral history to better define the history of present illness and to synthesize seemingly disparate findings into a cohesive diagnosis. Collateral information is particularly critical in patients with neurological or nonspecific symptoms, as it helps clarify deviations from the patient’s baseline mental status.
Conclusions: In conclusion, this case demonstrates that it is imperative for the hospitalist to maintain a wide differential diagnosis and ensure accurate communication despite language barriers to establish accurate collateral history to allow for comparisons with a prior baseline where there is any hint of deviation. This also serves as a reminder of the protean manifestations of M. tuberculosis including meningitis and isolated pleural plaques, as well as treatment complications such as paradoxical IRIS.