Tuberculous Meningitis with Occlusion of Middle Cerebral Artery

 
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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.


Clinical Problem :
A 7 month old girl was diagnosed as tuberculous meningitis {TBM} with hydrocephalus in April 2011 in view of fever for 15 days and convulsions. She was started on 4 drug antituberculous therapy {ATT} and steroids. Her CSF at that time showed 180 cells, cumm {90 percent polymorphs, 10 percent lymphocytes} with proteins of 142 gm, dl and sugar of 23 mg percent. Her CT brain showed basal exudates with hydrocephalus and ischemic infarcts in lentiform, caudate nucleus and anterior temporal lobe. Chest X-Ray showed right upper lobe consolidation. Her mother was also on ATT for past 2 months. The child had spasticity, dystonia and had lost all previous milestones. She was on doing well till Feb 2012 following which she developed increasing dystonia. A repeat CT scan showed large gliotic area in left basal ganglia and left frontotemporal periventricular white matter with moderate hydrocephalus and right middle cerebral artery {MCA} was not visualized but left MCA was totally occluded. She was advised to continue same. ATT and aspirin was added.


Question :
Why did the child get a vascular occlusion_?

Expert Opinion :
Vascular changes consisting of arterial narrowing with or without occlusion are frequently seen at autopsy in cases of tuberculous meningitis. {1} These changes lead to necrosis of localized areas of the brain and may be responsible for focal neurological deficits. {2} Vessel involvement only at the base of the brain, without peripheral vessel involvement, is strongly suggestive of tuberculous meningitis as this is the area that bears the brunt of inflammation in tuberculous meningitis. {2} The walls of the vessels immersed in thick gelatinous exudate are affected by inflammation and arteritis leading to vascular occlusion and thrombosis. Thus vascular occlusions are not uncommon in tuberculous meningitis.

References:
1. Doniach I. Changes in the meningeal vessels in acute and chronic {Streptomycin-treated} tuberculous meningitis. J Path Bact. 1949, LXI253
2. Airon RK, Jain AX, Mishra DS, Dua S, Sen Carotid angiography in tuberculous and pyogenic Meningitis. Indian J Tub. 1991` 38: 143- 147


Correct Answers :  yes 29%
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