A child with Tuberculous meningitis and clinical deterioration on Treatment
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A child with Tuberculous meningitis and clinical deterioration on Treatment
02/01/2014
02/01/2014
Dr Ira Shah
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Dr Ira Shah.
Medical Sciences Department, Pediatric Oncall, Mumbai, India.
ADDRESS FOR CORRESPONDENCE
Dr Ira Shah, Medical Sciences Department, Pediatric Oncall, 1, B Saguna, 271, B St. Francis Road, Vile Parle {W}, Mumbai 400056. |
Clinical Problem
Case Report: A 2½ year old boy presented with fever and right sided hemiplegia since 2 days. He had no vomiting, convulsion or altered sensorium. He was diagnosed as Tuberculous Meningitis 4 months back. At that time he had fever, convulsions and altered sensorium. His CSF had revealed 56 cells/cumm with 8% polymorphs and 92% lymphocytes, low CSF sugar (44 mg/dl) and normal proteins (44 mg%) CT brain had showed hypodensities in right parietal lobe with surrounding mass effect with moderate dilatation of ventricular system. He was started on 4 drug AKT with steroids and VP shunt had been done. At present, the child was on 2 drug AKT. On examination, his vital parameters were stable, VP shunt appeared patent. Fundoscopy showed bilateral optic disc pallor suggestive of optic atrophy CNS examination revealed right upper motor neuron facial palsy with right-sided hemiplegia.
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What is the cause of his present symptoms?
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Discussion
Since the child has been on Anti-tuberculous drugs since 4 months and now has deteriorated, one should consider the following:
1. Blocked VP shunt
2. Development of tuberculomas
3. Progressive TBM with left middle cerebral artery vasculitis.
A CT brain should be done as that would pick up all the 3 causes. A CT brain in this child revealed multiple ring enhancing granulomas. Intracranial tuberculomas are known to develop during treatment of Tuberculous Meningitis (TBM). They usually develop within weeks or couple of months after start of antituberculous therapy. The paradoxical phenomenon of appearance of tuberculomas while on successful antituberculous therapy is supposed to be due to an immunological reaction. Such patients should receive a prolonged (12-30 months) course of effective antituberculous drugs along with low dose steroids till the lesions resolve.
Thus a paradoxical appearance of Tuberculoma while on treatment with ATT should be looked for while monitoring a patient with TBM and in such patients, therapy would have to individualized, needs to be prolonged and continued till lesions disappear.
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| Compliance with ethical standards |
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Funding: None
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Conflict of Interest: None
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Cite this article as:
Shah I. A child with Tuberculous meningitis and clinical deterioration on Treatment. Pediatr Oncall J. 2005;3: 50.
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