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Tuberculous meningitis with dementia as the presenting symptom after intramedullary spinal cord tumor resection.

Kobayashi K, Imagama S, Ito Z, Ando K, Yagi H, Shinjo R, Hida T, Ito K, Ishikawa Y, Matsuyama Y, Ishiguro N - Nagoya J Med Sci (2015)

Bottom Line: The patient was diagnosed with senile dementia by a psychiatrist.However, the patient's symptoms progressively worsened.However the patient died 29 days after admission, subsequently M. tuberculosis was detected in the CSF sample.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.

ABSTRACT
Early-stage TB meningitis has no specific symptoms in patients, potentially leading to delayed diagnosis and consequently worsening prognosis. The authors present the fatal case with a delayed diagnosis of tuberculous (TB) meningitis with dementia as the presenting symptom after intramedullary spinal cord tumor resection. The medical records, operative reports, and radiographical imaging studies of a single patient were retrospectively reviewed. A 77-year-old man who underwent thoracic intramedullary hemangioblastoma resection for 2 times. The postoperative course was uneventful, but 1.5 months after surgery, the patient suffered from dementia with memory loss and diminished motivation and speech in the absence of a fever. No abnormalities were detected on blood test, brain computed tomography and cerebrospinal fluid (CSF) analysis. A sputum sample was negative for Mycobacterium tuberculosis in the QuantiFERON®-TB Gold (QFT-G) In-Tube Test and the tuberculin skin test was also negative. The patient was diagnosed with senile dementia by a psychiatrist. However, the patient's symptoms progressively worsened. Despite the absence of TB meningitis findings, we suspected TB meningitis from the patient's history, and administered a four-drug regimen. However the patient died 29 days after admission, subsequently M. tuberculosis was detected in the CSF sample. This case is a rare case of TB meningitis initially mistaken for dementia after intramedullary spinal cord tumor resection. Symptoms of dementia after intramedullary spinal cord tumor resection should first be suspected as one of TB meningitis, even if the tests for meningitis are negative. We propose that anti-tuberculosis therapy should be immediately initiated in cases of suspected TB meningitis prior to positive identification on culture.

No MeSH data available.


Related in: MedlinePlus

(a) Normal chest X-ray. (b) Brain CT showing slight ventricle enlargement. (c) Brain MRI showing ventricle enlargement.
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fig3: (a) Normal chest X-ray. (b) Brain CT showing slight ventricle enlargement. (c) Brain MRI showing ventricle enlargement.

Mentions: At 1.5 months after surgery, the patient suffered from dementia with memory loss and diminished motivation and speech in the absence of fever, and was readmitted. Tumor recurrence was not seen on MRI and blood parameters did not indicate an infection (white blood cell count [WBC], 7900 /mm3; C-reactive protein level [CRP], 0.1 mg/dL; erythrocyte sedimentation rate [ESR], 13 mm/h). No abnormalities were detected on chest X-ray (Fig. 3a), and cerebrospinal fluid (CSF) analysis was normal. Brain computed tomography (CT) (Fig. 2b) and MRI revealed slight enlargement of the ventricles (mild hydrocephalus) and the patient was diagnosed with senile dementia by a psychiatrist. However, after two weeks, his symptoms progressively worsened: dementia was more severe, he became disoriented, and his temperature increased to 39°C in association with a decrease in consciousness. At that time, the WBC count (12000 /mm3), CRP level (0.9 mg/dL) and ESR (42 mm/h) were elevated, and meropenem (2.0 g/day) was started. After a further one week, he became comatose and a second MRI revealed further hydrocephalus-induced ventricular dilatation (Fig. 2c). No tuberculosis bacteria in CSF were detected in a polymerase chain reaction (PCR) test, β-D-glucan in serum was normal, a sputum sample was negative for Mycobacterium tuberculosis in a QuantiFERON®-TB Gold (QFT-G) In-Tube Test, and a tuberculin skin test (TST) was also negative. Despite the absence of findings of TB meningitis, we suspected that this disease was present from the patient’s history, and based on the relatively slow progression of symptoms and the increases in adenosine deaminase (ADA), cell counts and protein and the decrease in glucose in the CSF. We administered a four-drug regimen (isoniazid, 0.3 g; rifampicin, 0.5 g; ethambutol, 0.75 g; streptomycin, 0.5 g), but the patient died 29 days after admission. Subsequently, M. tuberculosis was detected in the second CSF sample after a 28-day culture. The patient’s wife and son gave informed consent to submit this case study for publication.


Tuberculous meningitis with dementia as the presenting symptom after intramedullary spinal cord tumor resection.

Kobayashi K, Imagama S, Ito Z, Ando K, Yagi H, Shinjo R, Hida T, Ito K, Ishikawa Y, Matsuyama Y, Ishiguro N - Nagoya J Med Sci (2015)

(a) Normal chest X-ray. (b) Brain CT showing slight ventricle enlargement. (c) Brain MRI showing ventricle enlargement.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4664597&req=5

fig3: (a) Normal chest X-ray. (b) Brain CT showing slight ventricle enlargement. (c) Brain MRI showing ventricle enlargement.
Mentions: At 1.5 months after surgery, the patient suffered from dementia with memory loss and diminished motivation and speech in the absence of fever, and was readmitted. Tumor recurrence was not seen on MRI and blood parameters did not indicate an infection (white blood cell count [WBC], 7900 /mm3; C-reactive protein level [CRP], 0.1 mg/dL; erythrocyte sedimentation rate [ESR], 13 mm/h). No abnormalities were detected on chest X-ray (Fig. 3a), and cerebrospinal fluid (CSF) analysis was normal. Brain computed tomography (CT) (Fig. 2b) and MRI revealed slight enlargement of the ventricles (mild hydrocephalus) and the patient was diagnosed with senile dementia by a psychiatrist. However, after two weeks, his symptoms progressively worsened: dementia was more severe, he became disoriented, and his temperature increased to 39°C in association with a decrease in consciousness. At that time, the WBC count (12000 /mm3), CRP level (0.9 mg/dL) and ESR (42 mm/h) were elevated, and meropenem (2.0 g/day) was started. After a further one week, he became comatose and a second MRI revealed further hydrocephalus-induced ventricular dilatation (Fig. 2c). No tuberculosis bacteria in CSF were detected in a polymerase chain reaction (PCR) test, β-D-glucan in serum was normal, a sputum sample was negative for Mycobacterium tuberculosis in a QuantiFERON®-TB Gold (QFT-G) In-Tube Test, and a tuberculin skin test (TST) was also negative. Despite the absence of findings of TB meningitis, we suspected that this disease was present from the patient’s history, and based on the relatively slow progression of symptoms and the increases in adenosine deaminase (ADA), cell counts and protein and the decrease in glucose in the CSF. We administered a four-drug regimen (isoniazid, 0.3 g; rifampicin, 0.5 g; ethambutol, 0.75 g; streptomycin, 0.5 g), but the patient died 29 days after admission. Subsequently, M. tuberculosis was detected in the second CSF sample after a 28-day culture. The patient’s wife and son gave informed consent to submit this case study for publication.

Bottom Line: The patient was diagnosed with senile dementia by a psychiatrist.However, the patient's symptoms progressively worsened.However the patient died 29 days after admission, subsequently M. tuberculosis was detected in the CSF sample.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.

ABSTRACT
Early-stage TB meningitis has no specific symptoms in patients, potentially leading to delayed diagnosis and consequently worsening prognosis. The authors present the fatal case with a delayed diagnosis of tuberculous (TB) meningitis with dementia as the presenting symptom after intramedullary spinal cord tumor resection. The medical records, operative reports, and radiographical imaging studies of a single patient were retrospectively reviewed. A 77-year-old man who underwent thoracic intramedullary hemangioblastoma resection for 2 times. The postoperative course was uneventful, but 1.5 months after surgery, the patient suffered from dementia with memory loss and diminished motivation and speech in the absence of a fever. No abnormalities were detected on blood test, brain computed tomography and cerebrospinal fluid (CSF) analysis. A sputum sample was negative for Mycobacterium tuberculosis in the QuantiFERON®-TB Gold (QFT-G) In-Tube Test and the tuberculin skin test was also negative. The patient was diagnosed with senile dementia by a psychiatrist. However, the patient's symptoms progressively worsened. Despite the absence of TB meningitis findings, we suspected TB meningitis from the patient's history, and administered a four-drug regimen. However the patient died 29 days after admission, subsequently M. tuberculosis was detected in the CSF sample. This case is a rare case of TB meningitis initially mistaken for dementia after intramedullary spinal cord tumor resection. Symptoms of dementia after intramedullary spinal cord tumor resection should first be suspected as one of TB meningitis, even if the tests for meningitis are negative. We propose that anti-tuberculosis therapy should be immediately initiated in cases of suspected TB meningitis prior to positive identification on culture.

No MeSH data available.


Related in: MedlinePlus