Demyelination in tuberculous meningitis

Dr Ira Shah

doi:https://10.7199/ped.oncall.2017.30

Demyelination in tuberculous meningitis

Dr Ira Shah.

Consultant in Pediatric Infectious Diseases and Pediatric Hepatology, Nanavati Hospital and Incharge Pediatric HIV, TB and Liver Clinics, B J Wadia Hospital for Children, Mumbai, India.

ADDRESS FOR CORRESPONDENCE
Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056.

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Clinical Problem
A 7 years old girl presented with fever for 15 days, and 1 episode of generalised tonic clonic convulsion followed by loss of consciousness. Her sister was suffering from fibrocavitatory TB and was on treatment with anti-tuberculous therapy {ATT} from 3 months. On examination, the patient was comatose, had neck stiffness and spasticity of bilateral lower limbs. Cerebrospinal fluid {CSF} showed 300 cells, cumm {5 percent polymorphs, 95 percent lymphocytes}, 105 mg, dl of proteins and 20 mg, dl of sugar. CSF GeneXpert was positive for mycobacterium tuberculosis and was sensitive to rifampicin. She was started on 4 drug ATT along with steroids {for 2 months}. She responded to the same, but subsequently after 3 months of therapy, she presented with abnormal movements and behavioural problems. MRI brain showed extensive demyelination.

How common is demyelination in CNS TB_? How should it be treated_?

Discussion
Demyelination is commonly seen in tuberculous encephalopathy. It is characterized by diffuse brain edema and demyelination, which usually is extensive. {1} Patients present with impaired consciousness, seizures, disseminated intravascular coagulation, signs and symptoms of meningitis with or without spinal fluid changes. {2} Rarely central nervous system {CNS} tuberculosis presents as acute disseminated encephalomyelitis {ADEM}. {3}. Treatment with high dose steroids have proven to be useful. In our patient, we restarted oral steroids and ATT was continued to which she responded. She is on tapering doses of steroids.

Compliance with ethical standards

Funding: None

Conflict of Interest: None

References

Dastur DK. The pathology and pathogenesis of tuberculous encephalopathy and radiculomyelopathy: a comparison with allergic encephalomyelitis. Childs Nerv Syst. 1986;2:139. [CrossRef]
Cherian A, Thomas S. Central nervous system tuberculosis. Afr Health Sci. 2011;11(1):116-127. [PubMed] [PMC free article]
Masoodi I, Farooq O, Ahmad I, Bhat MY, Ahmad N Wani H, et al. Acute disseminated encephalomyelitis as the first presentation of CNS tuberculosis: report of a case with brief review. Ger Med Sci. 2010;8:Doc32. [PubMed] [PMC free article]