A 25-year-old Iranian female with complaints of headache and loss of consciousness was hospitalized on 2 Jun 2021. She presented with history of headache last 2 months. The patient’s headaches were mostly in the frontal lobes and parietal lobes. She had frequent outpatient visits to the physician for headaches and has taken analgesics during this time.
The patient was non-immunocompromised person. She had a history of COVID-19 infection 3 months ago. Her COVID-19 disease was mild. She had flu-like syndrome and lost her sense of smell and taste. She didn’t have COVID-19 pulmonary involvement and was not admitted to a hospital. Then the complaint of back pain began. The patient’s back pain was on the thoracic vertebrae. The patient back pain has continued until now.
The patient’s headache had worsened from 2 weeks before the admission. Finally, she came to the hospital with a severe headache. She had complaints of decreased level of consciousness, nausea, vomiting, diplopia, back pain and bladder incontinency. She had acute onset of lower limb weakness on day prior to the admission that become unable to even stand independently. Patient did not have any medical problem previously. She did not have any cough. There was no family history of TB. She has lost 5 kg in the last month. She had moved from village to city 22 years ago.
On admission, she was lethargic and confused. She had delirium. On physical examination she was afebrile. Signs of meningeal irritation were present. Lower limbs power decreased (4/5). She had nystagmus on eye examination.
Brain magnetic resonance images (MRI) showed diffused leptomeningeal enhancement. Mild hydrocephaly was seen too. There was abnormal signal area with restriction in splenium of corpus callosum without enhancement (Figure 1).
Spinal MRI showed abnormal signal intensity with enhancement in T8-T9 disc space, adjacent end plates, bodies and posterior elements and small part of body of T10 associated prevertebral soft tissue edema and enhancement (Figure 2).
On chest computed tomographic scan, poorly spread nodularity was seen throughout the lungs suggesting miliary tuberculosis. Multiple lymphadenopathies were seen in the left axillary and mediastinum that some of them had calcifications (Figure 3).
Laboratory investigations showed elevated WBC in Cerebral Spinal Fluid (60% lymphocyte), high CSF protein and low glucose (Table 1). Mycobacterium tuberculosis detected with polymerase chain reaction (PCR) of cerebral spinal fluid (CSF). Rifampin resistance not detected with the Expert MTB/RIF assay. CMV, EBV, HSV1,2 and VZV didn’t detect with PCR of CSF. White blood cell count was 5,900 cells/mm3, (90% neutrophils, 8% lymphocytes). C-reactive protein level was 21 mg/dl. Erythrocyte sedimentation rate (ESR) level was 31 mm/h. HIV serology was negative. Liver function tests parameters were containing: Aspartate transaminase (AST) 57 U/L, Alanine transaminase (ALT) 53 U/L, Alkaline phosphatase (ALP) 264 U/L, serum bilirubin total 0.8 mg/dl and direct 0.5 mg/dl. SARS CoV2 RT-PCR from nasopharyngeal and throat swabs was negative.
Patient started on anti-tuberculosis drugs and steroid. She was started on isoniazid 300mg, rifampin 600mg, pyrazinamide 1200mg and ethambutol 825mg once daily. According to objective neurological findings, prednisolone 80 mg/day was required, which was gradually tapered and discontinued through 6 weeks. Analysis of Cerebral Spinal Fluid (CSF) on the eighth day of treatment was better. Post treatment showed significant neurological improvement. The patient’s consciousness gradually improved during the first week of treatment. Nystagmus and diplopia was improved during the second week. The patient`s headache subsided and was mostly after waking up during the third week. Delirium was completely gone in the third week. From the fourth week, force of her lower limbs improved and she was able to stand independently. Despite T8-T9 spondylodiscitis, the patient had not neurological deficits and cord compression. According to the neurosurgeon consulting, she did not need to surgery and was treated with medical treatment. The patient’s liver function tests increased at the beginning of treatment but gradually decreased after 2 weeks of treatment (Table2). The increase in liver function tests was less than 5 fold normal and the patient did not show signs and symptoms of acute hepatitis, so the medication continued. On day 18th of admission, the patient was discharged home in good general condition. The patient was prescribed anti tuberculous treatment for total duration of 12 months with a follow up appointment at the TB clinic. She received prednisolone for first 6 weeks’ duration and her prednisolone decreased weekly.
Table 1 Analysis of Cerebral Spinal Fluid (CSF)
|
Variable
|
CSF 1th Day
|
CSF 8th Day
|
White blood cells (cells/ML)
Red blood cells (cells/ML)
Neutrophils (%)
Lymphocyte (%)
Glucose (mmol/L) CSF/G Serum
LDH (U/L)
Protein (g/L)
|
50
3
40
60
39/109
149
130
|
2
2
-
-
65/120
68
19.5
|
Table 2 Liver Function Tests during treatment
|
|
Day
|
1th
|
3th
|
5th
|
7th
|
9th
|
11th
|
13th
|
15th
|
17th
|
19th
|
AST
ALT
|
57
53
|
80
53
|
115
85
|
50
69
|
76
111
|
137
135
|
128
125
|
84
110
|
52
82
|
50
62
|