Diagnostic Dilemma


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.

How should this child be treated further?
Expert Opinion :
We continued the same treatment. TB PCR may remain positive for a long time as it may even pick up dead bacilli. TB culture is negative. We repeated MRI after 3 months, and that showed a decrease in the size of granulomas and a decrease in the basal exudates.
Answer Discussion :
Nitin Prajapati
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