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|LETTER TO EDITOR
|Year : 2021 | Volume
| Issue : 6 | Page : 1859-1860
Large Cerebral Infarction in Tuberculous Meningitis: Case Report of an Uncommon Complication
Ahmad Ozair, Arjumand Faruqi, Imran Rizvi, Ravindra K Garg
Department of Neurology, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Submission||09-Jul-2019|
|Date of Decision||02-Sep-2019|
|Date of Acceptance||07-Feb-2020|
|Date of Web Publication||23-Dec-2021|
Dr. Imran Rizvi
Department of Neurology, King George's Medical University (KGMU), Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ozair A, Faruqi A, Rizvi I, Garg RK. Large Cerebral Infarction in Tuberculous Meningitis: Case Report of an Uncommon Complication. Neurol India 2021;69:1859-60
We here present an illustrative case of tuberculous meningitis (TBM) with a rare complication of large cerebral infarction. TBM is the most common type of chronic CNS infection in developing countries. Strokes occur in 15–57% of TBM cases; mostly being associated with advanced illness.
An 18-year-old male was brought to a tertiary care centre in northern India with high-grade fever and headache for 3 months; followed by right-sided bodily weakness and inability to speak, for a week. He was conscious, having neck rigidity, positive Kernig's sign, global aphasia, and hemiplegia. Brain MRI suggested basal exudates, hydrocephalus, and tuberculoma in the left cerebellar hemisphere. Diffusion-weighted imaging indicated large infarct involving anterior cerebral artery (ACA) and middle cerebral artery (MCA) territories [Figure 1]. Guarded lumbar puncture was done in view of focal deficit and mass effect. CSF analysis revealed protein 3.5 g/L, glucose 1.66 mmol/L (blood glucose 7.2 mmol/L), leukocyte count of 250 with lymphocytosis, and positive Gene Xpert MTB/RIF assay. He was started on first-line anti-tuberculosis therapy (ATT), steroids, and aspirin. After 3 months, his fever and headache had improved but he still had hemiparesis and aphasia, confirming the diagnosis of grade 3 TBM. After 12 months of ATT coverage and follow-up, his motor function had improved with some residual deficits.
|Figure 1: (a) Post-contrast T1-weighted image showing basal exudates (oblique arrow), hydrocephalous as evident by the dilated temporal horn of lateral ventricle (horizontal arrow) (b) Ring-enhancing lesion suggestive of tuberculoma (arrow) in the left cerebellar hemisphere. (c) Diffusion-weighted imaging showing infarct involving left anterior cerebral artery (ACA) and middle cerebral artery (MCA) territories (d) 3D time-of-flight MR angiography showing attenuated left ACA (horizontal arrow) and MCA (vertical arrow)|
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Although occurring in just 1% of the 9 million annual tuberculosis cases worldwide, TBM kills or severely disables nearly half of the people affected. Most cerebral infarcts seen in TBM are small and asymptomatic, secondary to the involvement of branches of major vessels., Large infarcts from occlusion of the posterior, middle, and anterior cerebral arteries are rare, for which diffusion-weighted imaging is the investigation of choice. These commonly occur in 'tuberculous zone', that is, the area supplied by the medial striate and thalamo-perforating arteries.,
Despite multiple historical attempts at creating validated clinical diagnostic criteria, it is still challenging to reliably arrive at or exclude the diagnosis of TBM using signs, symptoms, and routine investigations, especially in areas of low prevalence. Lumbar puncture is, thus, usually performed despite the risk of herniation. GeneXpert MTB/RIF assay (Cepheid, Sunnyvale, CA) is the currently recommended, WHO-endorsed tool for confirmation. Because treatment delay is the strongest predictor of death, it is critical this rapid diagnostic method becomes standard practice across developing countries.
Current first-line ATT drugs still are isoniazid, rifampicin, pyrazinamide, and ethambutol, to be given for 9–12 months. Regional treatment guidelines must be followed since many areas have high rates of multidrug-resistant tuberculosis, wherein GeneXpert is especially helpful.
However, significant gaps in evidence-based management remain. A recent Cochrane review has concluded that due to the presence of confounded observational studies, any inferences regarding the shorter duration of ATT in TBM are inappropriate. There is still a paucity of RCTs demonstrating the efficacy of linezolid, bedaquiline, and a high dose of rifampicin and fluoroquinolones in TBM, for them to be endorsed as the standard of care. Aspirin, even though provided here for stroke, as is the routine practice in many institutions, still has insufficient evidence of significant stroke risk reduction in TBM, some of which may be predicted by LTA4H screening. High-quality, adequately-powered RCTs are urgently warranted to answer these questions.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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