Diagnostic Dilemma

TBM WITH TUBERCULOMA


Author: Pediatric Oncall
Question
A 2½ years old boy presented with fever and vomiting for 9 days. He was detected to have tuberculous meningitis (TBM) at the age of 1½ years in view of right sided hemiparesis with communicating hydrocephalus and right frontal periventricular tuberculoma. He was treated with antituberculous therapy (ATT) for 9 months. He was off ATT for the past 3 months. A current CT brain showed 2 ring enhancing lesions with left sided cerebral atrophy and dilated ventricles. He was restarted on Category 2 ATT consisting of Isoniazid (H), Rifampicin (R), Ethambutol (E), Pyrazinamide (Z) and Streptomycin (S) along with steroids. A month later it was found that his aunt had drug resistant TB (DR-TB). The child’s ATT was then shifted to Ofloxacin, Ethionamide, Amikacin, PAS and cycloserine. MRI brain after 9 months of therapy showed extensive basal exudates with ring enhancing lesions. His cerebrospinal fluid (CSF) was done that showed positive TB PCR but CSF TB MGIT culture was negative.

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