Case Presentation: Case:Patient is a 66yo M with a history of malignant neoplasm of the bladder who presented to Michigan Medicine for 1 month of altered mental status. At the time of presentation, family stated that for the past month the patient began having episodes of “confusion” in which the patient is unable to recognize family and friends and engages in conversation that does not “make sense.” At this time he has also been weak in his lower extremities and unable to walk. He denies fever, chills, and memory difficulties prior to this month. He did however endorse focal back pain, a history of steroid injections during the past month for relief of the pain, and episodes of HA, vertigo, and hyponatremia at outside hospitals.On admission labs were significant for Na 129, UDS positive for cannabinoids, and urine culture with no growth. PET scan showed hypermetabolism in the spinal canal. MRI brain and spine indicated enhancement of the meninges at the lumbar region. CSF was significant for negative cytology, lymphocytic predominance, markedly high protein (2,907), and low glucose. In order to distinguish between infection and malignancy the patient then underwent an L1 to L4 laminectomy with intradural biopsy and debridement of the mass. Biopsy showed necrotizing granulomatous inflammation. Based on prior negative TB quantiferon and fungal testing, the patient was given a presumptive diagnosis of neurosarcoidosis and started on a 2 month steroid taper. Four weeks later, follow up culture of the mass returned positive for Mycobacterium tuberculosis and the patient was started on RIPE therapy. He was later identified to have prior exposure to BCG and did live in an endemic area.
Discussion: Discussion:Mycobacterium Tuberculous Meningitis accounts for roughly 1 percent of all cases of TB and 5 percent of extrapulmonary disease in immunocompetent individuals. At this time the case fatality rate remains relatively high – 15-40%- despite RIPE treatment regimen. (1). Patients with tuberculous meningitis typically present with 2-3 weeks of a prodromal phase consisting of malaise, HA, low grade fever and personality change followed by increasingly severe neurologic features (lethargy, confusion, CN signs), followed by paralysis and hemiparesis. (2). Diagnosis is made via CSF studies which demonstrate low glucose concentration, elevated protein, and lymphocytic pleocytosis. Examination of CSF by acid-fast stain and culture is gold standard. Prognosis is dismal in patients who are not treated, as death typically ensues within 5-8 weeks of onset of illness. (3).
Conclusions: Conclusion:In patients with subacute onset mental status changes accompanied by focal enhancement of the meninges, it is important to consider non-viral/non-bacterial causes of meningitis, specifically, Mycobacterium Tuberculosis as an etiology even when TB quantiferon test is negative. Early identification and treatment of MTb is important as death can ensue within weeks of disease onset.