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Seizures in an immunocompromised adolescent: a case report.

Bataduwaarachchi VR, Tissera N - J Med Case Rep (2015)

Bottom Line: Immunocompromised patients are at a higher risk of contracting tuberculosis than the healthy population.The efficacy of isoniazid prophylaxis in patients with immune suppression warrants further study.We present a regimen that successfully treated tuberculous cerebral vasculitis.

View Article: PubMed Central - PubMed

Affiliation: Department of Pharmacology and Pharmacy, Faculty of Medicine University of Colombo, PO Box 271, Kynsey Road, Colombo 8, Sri Lanka. vipbat7@yahoo.com.

ABSTRACT

Introduction: Tuberculosis is a progressive and disabling infection predominantly seen in low-income and middle-income countries. Immunocompromised patients are at a higher risk of contracting tuberculosis than the healthy population. The presentation may also be atypical, leading to delay in diagnosis. We report the first case of tuberculous cerebral vasculitis presenting with epilepsia partialis continua.

Case presentation: A 17-year-old adolescent boy of Sri Lankan Moor heritage was taking long-term immunosuppressants for nephrotic syndrome. He presented to hospital with focal fits affecting his left arm. He later developed choreiform movements of the same arm, progressing to epilepsia partialis continua and weakness. The gradually evolving focal neurological signs and underlying immunosuppression raised the possibility of localized cerebral infection or inflammation. Analysis of his cerebrospinal fluid showed lymphocytosis with normal cellular morphology. Magnetic resonance imaging was suggestive of progressive vasculitic infarctions of the cerebral cortex and basal ganglia. There was no evidence of active autoimmune or viral disease on hematological investigations, but molecular amplification detected Mycobacterium tuberculosis in his cerebrospinal fluid. Although our patient had been established on isoniazid preventive treatment for eight months before the episode, tuberculosis was nonetheless considered to be the most likely cause of the cerebral vasculitis. He was treated with a trial of anti-tuberculosis treatment, including streptomycin and adjunctive steroids, and made an uneventful recovery.

Conclusion: Clinicians should have a high index of suspicion for tuberculosis infection in patients with compromised immunity and other risk factors. The pathophysiological mechanisms underpinning cerebral vasculitis and epilepsia partialis continua are not completely understood. The efficacy of isoniazid prophylaxis in patients with immune suppression warrants further study. We present a regimen that successfully treated tuberculous cerebral vasculitis.

No MeSH data available.


Related in: MedlinePlus

Magnetic resonance image: transverse section of the brain 1 month after the onset of illness. This section shows new involvement of the right cerebral cortex (right middle meningeal arterial territory) with vasogenic edema
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Fig2: Magnetic resonance image: transverse section of the brain 1 month after the onset of illness. This section shows new involvement of the right cerebral cortex (right middle meningeal arterial territory) with vasogenic edema

Mentions: Non-enhanced computed tomography (CT) of his brain showed no abnormalities on the first day of admission. On the third day of admission, T2-weighted MRI of his brain revealed high intensity signals in his right hippocampal gyrus, right putamen, and the head of the caudate nucleus, suggestive of multiple infarctions (Fig. 1). Magnetic resonance angiography and venography were normal, however, excluding the possibility of macrovascular occlusion. MRI was repeated 1 month later because of the progressive nature of his symptoms and signs, and showed an increase in the size of original lesions and the development of new areas of involvement in the cerebral cortex with associated vasogenic edema (Figs. 2 and 3). At the same time, a repeat CT scan showed infarctions in the cortex but no basal ganglia involvement (Fig. 4). Even though areas of infarction caused by a single event may have evolving radiological features, the progressive clinical manifestations we observed favored an on-going, persistent, and escalating brain injury. We repeated the lumbar puncture, and CSF samples were sent for TB and fungal studies. Polymerase chain reaction (PCR) testing for TB was positive in two independent samples performed at two different laboratories. A quantitative PCR assay is reportedly an accurate and reliable means of quantitative detection of M. tuberculosis DNA in CSF samples owing to the development of a new-mutation plasmid as an internal control [12]. Another study reported that the technique was less sensitive but more specific for the diagnosis of tuberculous meningitis in individuals with HIV infection, individuals living in a TB-endemic setting, particularly when a centrifuged CSF pellet is used (sensitivity 62 %, specificity 95 %) [13]. TB was considered the most likely cause for cerebral vasculitis in our patient based on these findings. This case highlights the effectiveness of TB PCR in the diagnosis of CNS TB, obviating the need for brain biopsy.Fig. 1


Seizures in an immunocompromised adolescent: a case report.

Bataduwaarachchi VR, Tissera N - J Med Case Rep (2015)

Magnetic resonance image: transverse section of the brain 1 month after the onset of illness. This section shows new involvement of the right cerebral cortex (right middle meningeal arterial territory) with vasogenic edema
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4552135&req=5

Fig2: Magnetic resonance image: transverse section of the brain 1 month after the onset of illness. This section shows new involvement of the right cerebral cortex (right middle meningeal arterial territory) with vasogenic edema
Mentions: Non-enhanced computed tomography (CT) of his brain showed no abnormalities on the first day of admission. On the third day of admission, T2-weighted MRI of his brain revealed high intensity signals in his right hippocampal gyrus, right putamen, and the head of the caudate nucleus, suggestive of multiple infarctions (Fig. 1). Magnetic resonance angiography and venography were normal, however, excluding the possibility of macrovascular occlusion. MRI was repeated 1 month later because of the progressive nature of his symptoms and signs, and showed an increase in the size of original lesions and the development of new areas of involvement in the cerebral cortex with associated vasogenic edema (Figs. 2 and 3). At the same time, a repeat CT scan showed infarctions in the cortex but no basal ganglia involvement (Fig. 4). Even though areas of infarction caused by a single event may have evolving radiological features, the progressive clinical manifestations we observed favored an on-going, persistent, and escalating brain injury. We repeated the lumbar puncture, and CSF samples were sent for TB and fungal studies. Polymerase chain reaction (PCR) testing for TB was positive in two independent samples performed at two different laboratories. A quantitative PCR assay is reportedly an accurate and reliable means of quantitative detection of M. tuberculosis DNA in CSF samples owing to the development of a new-mutation plasmid as an internal control [12]. Another study reported that the technique was less sensitive but more specific for the diagnosis of tuberculous meningitis in individuals with HIV infection, individuals living in a TB-endemic setting, particularly when a centrifuged CSF pellet is used (sensitivity 62 %, specificity 95 %) [13]. TB was considered the most likely cause for cerebral vasculitis in our patient based on these findings. This case highlights the effectiveness of TB PCR in the diagnosis of CNS TB, obviating the need for brain biopsy.Fig. 1

Bottom Line: Immunocompromised patients are at a higher risk of contracting tuberculosis than the healthy population.The efficacy of isoniazid prophylaxis in patients with immune suppression warrants further study.We present a regimen that successfully treated tuberculous cerebral vasculitis.

View Article: PubMed Central - PubMed

Affiliation: Department of Pharmacology and Pharmacy, Faculty of Medicine University of Colombo, PO Box 271, Kynsey Road, Colombo 8, Sri Lanka. vipbat7@yahoo.com.

ABSTRACT

Introduction: Tuberculosis is a progressive and disabling infection predominantly seen in low-income and middle-income countries. Immunocompromised patients are at a higher risk of contracting tuberculosis than the healthy population. The presentation may also be atypical, leading to delay in diagnosis. We report the first case of tuberculous cerebral vasculitis presenting with epilepsia partialis continua.

Case presentation: A 17-year-old adolescent boy of Sri Lankan Moor heritage was taking long-term immunosuppressants for nephrotic syndrome. He presented to hospital with focal fits affecting his left arm. He later developed choreiform movements of the same arm, progressing to epilepsia partialis continua and weakness. The gradually evolving focal neurological signs and underlying immunosuppression raised the possibility of localized cerebral infection or inflammation. Analysis of his cerebrospinal fluid showed lymphocytosis with normal cellular morphology. Magnetic resonance imaging was suggestive of progressive vasculitic infarctions of the cerebral cortex and basal ganglia. There was no evidence of active autoimmune or viral disease on hematological investigations, but molecular amplification detected Mycobacterium tuberculosis in his cerebrospinal fluid. Although our patient had been established on isoniazid preventive treatment for eight months before the episode, tuberculosis was nonetheless considered to be the most likely cause of the cerebral vasculitis. He was treated with a trial of anti-tuberculosis treatment, including streptomycin and adjunctive steroids, and made an uneventful recovery.

Conclusion: Clinicians should have a high index of suspicion for tuberculosis infection in patients with compromised immunity and other risk factors. The pathophysiological mechanisms underpinning cerebral vasculitis and epilepsia partialis continua are not completely understood. The efficacy of isoniazid prophylaxis in patients with immune suppression warrants further study. We present a regimen that successfully treated tuberculous cerebral vasculitis.

No MeSH data available.


Related in: MedlinePlus