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Table of Contents    
LETTER TO EDITOR
Year : 2021  |  Volume : 69  |  Issue : 3  |  Page : 762-763

A Scary Tale of Meningoencephalitis Where Aetiology Remained Elusive; But Finally, Patient Had The “Last Laugh”


1 Department of Neurology, Apollo Gleneagles Hospital, Kolkata, West Bengal, India
2 Department of Radiology, Apollo Gleneagles Hospital, Kolkata, West Bengal, India
3 Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, L9 7LJ, UK

Date of Submission03-Jun-2020
Date of Decision15-Jun-2020
Date of Acceptance13-Jul-2020
Date of Web Publication24-Jun-2021

Correspondence Address:
Dr. Chakraborty Debabrata
64/4A/9, Beliaghata Main Road, Kolkata - 700 010, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.319232

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How to cite this article:
Debabrata C, Sadanand D, Gobinda P, Abhiji D. A Scary Tale of Meningoencephalitis Where Aetiology Remained Elusive; But Finally, Patient Had The “Last Laugh”. Neurol India 2021;69:762-3

How to cite this URL:
Debabrata C, Sadanand D, Gobinda P, Abhiji D. A Scary Tale of Meningoencephalitis Where Aetiology Remained Elusive; But Finally, Patient Had The “Last Laugh”. Neurol India [serial online] 2021 [cited 2021 Jul 25];69:762-3. Available from: https://www.neurologyindia.com/text.asp?2021/69/3/762/319232




Sir,

A 31-year-old lady with no known comorbidity attended ER with six days of febrile illness and confusion. She had prominent meningeal sign without focal deficit. Her cerebrospinal picture (CSF) picture revealed 250 cells, 88% lymphocytes, 182 mg% protein, and 48 mg% sugar. MRI of the brain revealed diffuse leptomeningeal enhancement in both cerebral hemispheres and around brainstem [Figure 1]. Viral or pyogenic meningoencephalitis was kept as possibility, so, antibiotics and antiviral were started initially. A detailed infective comprehensive panel including common microorganisms was found to be negative and so was CSF culture. Her inflammatory markers were normal and blood culture was negative. The serology for venereal diseases, Weil Felix test, and vasculitis markers was unremarkable.
Figure 1: MRI showing diffuse leptomeningeal enhancement in cerebral hemispheres, around brainstem

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Fever persisted and remained around 104°F even after ten days of antibiotics.

At this juncture, we started antitubercular drugs with steroids. Fever subsided, cognition almost touched baseline within a week.

Unfortunately, the day before discharge, she became drowsy, with acute retention of urine. We ruled out nosocomial infection; repeat CSF picture was better and detailed workup was negative again. However, MRI imaging during this time revealed multiple new lesions [Figure 2]. We increased steroid attributing the clinical deterioration to an inflammatory reaction and continued antitubercular drugs. Her cognitive part started improving from the third day itself and a repeat MRI of the brain six days later also detected significant improvement [Figure 3].
Figure 2: MRI showing new hypersignal in corpus callosum, bilateral putamen, thalami, pons, medulla and adjoining cerebellar peduncle with ependymal hyperintensity along lateral and fourth ventricle

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Figure 3: Improvement of lesions seven days later

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She was finally back to normal within a month and is doing very well for a year since we started antitubercular treatment. We have planned to continue it for six more months.

We dealt with a complicated case of meningoencephalitis where clinical signs evolved with time and there was a deterioration following a phase of improvement, but etiology remained elusive. When diagnostic tests are inconclusive, it is probably wise to consider atypical presentation of common micro-organisms.

We started ATT (antitubercular treatment) in our case because of the following reasons:

  1. India has an extremely high incidence of tuberculosis of around 193/100,000 population[1] with a variable presentation. Although detection of tubercle bacilli by AFB staining or culture is the most important step of CSF study, its yield is low and even serial tests may be negative.[2],[3] In a study of Indian population, PCR was positive in only up to 75% of patients, even in highly probable group of tubercular meningitis and 91% of them improved with antitubercular therapy.[4] So, sometimes we need to depend on clinical findings and supportive evidence to diagnose and treat this deadly disease.[2]
  2. She is a young lady with a family history of tuberculosis. CT scan of chest revealed pleural thickening and her CSF picture revealed lymphocytic predominance with persistent hypoglycorrhachia supporting tuberculosis as one of the possibilities.[3]
  3. The detailed diagnostic workup for meningoencephalitis of our patient was inconclusive and she continued to deteriorate with standard treatment. Hence, in this desperate situation, we finally decided to start ATT empirically because late initiation of ATT is associated with high mortality, as per Indian literature.[2]


The high prevalence and fatality of meningoencephalitis worldwide are well known. So, we should have a treatment guideline for meningoencephalitis where definite etiology remains elusive. The diagnostic criteria and treatment plan for CNS tuberculosis are widely diverse in India and is an important field of future research.[5]

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.

Acknowledgement

We acknowledge the immense trust of the family members of the patient on us and their support to us in the time of need.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Global Tuberculosis Report 2020. https://www.who.int/teams/global-tuberculosis-programme/data.  Back to cited text no. 1
    
2.
Aher A, Paithankar M, Bhurke B. Study of central nervous system tuberculosis. J Assoc Physicians India 2018;66:41-4.  Back to cited text no. 2
    
3.
Garg RK. Tuberculosis of the central nervous system. Postgrad Med J 1999;75:133-40.  Back to cited text no. 3
    
4.
Ahuja GK, Mohan KK, Prasad K, Behari M. Diagnostic criteria for tuberculous meningitis and their validation. Tuber Lung Dis 1994;75:149-52.  Back to cited text no. 4
    
5.
Khadilkar SV, Kadam ND, Kulkarni RV, Meshram CM, Meshram AR, Patel BA, et al. Guidelines versus ground lines: Tuberculosis of the central nervous system. Neurol India 2019;67:787-91.  Back to cited text no. 5
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