GRAND ROUNDS AND TEACHING FILES
Hydrocephalus in tuberculous meningitis


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Clinical Problem:


Ira Shah
Medical Sciences Department, Pediatric Oncall, Mumbai, India.

Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056, India.


A 4 years old girl was referred as she had been on antituberculous therapy {ATT} for past 2 years 8 months. At age of 1 year 4 months, she was diagnosed as tuberculous meningitis {TBM} with hydrocephalus and was started on ATT and underwent ventriculoperitoneal {VP} shunt insertion. She was alright was next 6 months and at 2 years she developed drowsiness with right sided hemiparesis. A CT brain showed large granuloma anterior to brain stem causing upper cervical cord compression. She was thus restarted on steroids which was given for 2 months. At 2 years 4 months, she developed an encysted collection of fluid 16.4 x 13.9 cm underneath the anterior abdominal wall that required excision. At 2 years 7 months of age she developed a peritoneal pseudocyst and hence VP shunt was removed and a ventriculo-atrial {VA shunt} was put. Abdominal lymphnode biopsy was done at the same time where mycobacterium tuberculosis was isolated and 2 drugs ATT consisting of Isoniazid {H}, Rifampicin {R} was continued. At 3 years 4 months of age, MRI brain was done which showed substantial regression of confluent granulomas in retroclivum region. At 3 years 10 months of age, she had headache and a fall following which VA shunt broke and again a VP shunt was reinserted. CT brain now showed disappearance of granuloma. At 4 years of age, at the time of referral, the child was asymptomatic, had normal milestones and no focal neurological deficit. Her weight was 14 kg, height was 84.5 cm, head circumference was 46 cm. Her hearing assessment, ophthalmological assessment was normal and EEG was also normal. Her ATT was thus stopped and she was advised regular follow up.



Do all patients with TBM and hydrocephalus require a VP shunt_?

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