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Table of Contents    
LETTER TO EDITOR
Year : 2021  |  Volume : 69  |  Issue : 6  |  Page : 1859-1860

Large Cerebral Infarction in Tuberculous Meningitis: Case Report of an Uncommon Complication


Department of Neurology, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission09-Jul-2019
Date of Decision02-Sep-2019
Date of Acceptance07-Feb-2020
Date of Web Publication23-Dec-2021

Correspondence Address:
Dr. Imran Rizvi
Department of Neurology, King George's Medical University (KGMU), Lucknow - 226 003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.333498

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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

How to cite this URL:
Ozair A, Faruqi A, Rizvi I, Garg RK. Large Cerebral Infarction in Tuberculous Meningitis: Case Report of an Uncommon Complication. Neurol India [serial online] 2021 [cited 2022 Jan 19];69:1859-60. Available from: https://www.neurologyindia.com/text.asp?2021/69/6/1859/333498




Dear Sir,

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.[1] Strokes occur in 15–57% of TBM cases; mostly being associated with advanced illness.[2]

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.[1] Most cerebral infarcts seen in TBM are small and asymptomatic, secondary to the involvement of branches of major vessels.[2],[3] Large infarcts from occlusion of the posterior, middle, and anterior cerebral arteries are rare, for which diffusion-weighted imaging is the investigation of choice.[2] These commonly occur in 'tuberculous zone', that is, the area supplied by the medial striate and thalamo-perforating arteries.[2],[3]

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.[1] 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,[1] 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.[4] 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,[5] some of which may be predicted by LTA4H screening.[1] High-quality, adequately-powered RCTs are urgently warranted to answer these questions.[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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Thwaites GE, van Toorn R, Schoeman J. Tuberculous meningitis: More questions, still too few answers. Lancet Neuro 2013;12:999-1010.  Back to cited text no. 1
    
2.
Misra UK, Kalita J, Maurya PK. Stroke in tuberculous meningitis. J Neurol Sci 2011;303:22-30.  Back to cited text no. 2
    
3.
Tai MS, Viswanathan S, Rahmat K, Nor HM, Kadir KA, Goh KJ, et al. Cerebral infarction pattern in tuberculous meningitis. Sci Rep 2016;13:38802.  Back to cited text no. 3
    
4.
Jullien S, Ryan H, Modi M, Bhatia R. Six months therapy for tuberculous meningitis. Cochrane Database Syst Rev 2016;9:CD012091.  Back to cited text no. 4
    
5.
Yadav R. Role of aspirin as an adjuvant therapy in tuberculous meningitis in adults: The time has come for a phase III randomized controlled trial. Neurol India 2018;66:1678-9.  Back to cited text no. 5
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