Cerebral Vasculitis in Meningeal Tuberculosis: A Case Study

Meningeal tuberculosis (MTB) is particularly frequent in children less than five years old and it is often overlooked due to non-specific symptoms. The Portuguese annual incidence of MTB in children aged under five years was less than 1:10.000.000 inhabitants (2011 – 2016).

An 18-month-old girl was admitted due to poor feeding and lethargy, with a four-month history of intermittent fever, enlarged cervical lymph nodes and weight loss. Primary care follow-up was maintained by different general practitioners. She had not been immunized with BCG vaccine. Cranial CT scan displayed normal ventricular size and lumbar puncture showed pleocytosis, polymorphonuclear neutrophils predominance and hypoglycorrhachia. Empirical treatment for CNS infection was initiated and she was transferred to our tertiary hospital. Due to clinical suspicion of MTB, tuberculostatic therapy (four-drug regimen) was initiated within 24 hours, as well as adjunctive therapy with glucocorticoids. Over the next 48 hours, she presented tonic-clonic seizures and progressive impaired consciousness. Repeated CT scan revealed hydrocephalus requiring admission in intensive care unit for external ventricular drain (EVD). Subsequent MRI revealed a large vessel vasculitis. Positive results for Mycobacterium tuberculosis were obtained by cerebrospinal fluid (CSF) culture and by PCR in CSF, bronchoalveolar lavage and gastric aspirate specimens. Chest CT scan exhibited a miliary pattern. Prompt screening of household contacts identified the index-case (her father) in collaboration with public health department. Rapid progression of vasculitis lead to refractory intracranial hypertension with need of decompressive hemicraniectomy. Ventriculoperitoneal shunt was necessary due to unsuccessful EVD removal. She maintained severe neurologic deficits on one-year follow-up.

In the reported case, stage of disease at presentation and complications (especially cerebral vasculitis) were possibly the major determinants of neuropsychomotor sequelae. It is of paramount importance recognizing early MTB stages for prompt management. Screening close contacts is vital, reinforcing the need of optimizing collaboration with public health departments.