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A Case of Disseminated Multidrug-Resistant Tuberculosis involving the Brain.

Jung EK, Chang JY, Lee YP, Chung MK, Seo EK, Koo HS, Choi HJ - Infect Chemother (2016)

Bottom Line: However, her headache and brain lesion worsened.Linezolid was added to intensify the treatment regimen, and steroid was added for the possibility of paradoxical response.Kanamycin was discontinued 6 months after initiation of the treatment; she was treated for 18 months with susceptible drugs and completely recovered.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea.

ABSTRACT
We report a case of a 23-year-old female immigrant from China who was diagnosed with multidrug-resistant tuberculosis affecting her lung and brain, resistant to the standard first-line therapeutics and streptomycin. She was treated with prothionamide, moxifloxacin, cycloserine, and kanamycin. However, her headache and brain lesion worsened. After the brain biopsy, the patient was confirmed with intracranial tuberculoma. Linezolid was added to intensify the treatment regimen, and steroid was added for the possibility of paradoxical response. Kanamycin was discontinued 6 months after initiation of the treatment; she was treated for 18 months with susceptible drugs and completely recovered. To our knowledge, this case is the first multidrug-resistant tuberculosis that disseminated to the brain in Korea.

No MeSH data available.


Related in: MedlinePlus

(A) Brain magnetic resonance image (MRI) on hospital day 31 showed brain edema and lesions on subcortical white matter of left frontal lobe and left temporal lobe which high signal intensity on T2-weighted image in the subcortical white matter of left frontal lobe (30×22 mm) and temporal lobe (24×20 mm), on coronal view (left) and transverse view (right). (B) Brain CT on hospital day 91. Ring like enhanced lesion with calcification in left frontal lobe (34×22 mm) and temporal lobe (28×19 mm) with enlargement of primary mass and progression of brain edema. (C) Brain CT After 20 months of anti-tuberculosis treatment, residual low density is in left frontal subcortical white matter without enhancement.
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Figure 3: (A) Brain magnetic resonance image (MRI) on hospital day 31 showed brain edema and lesions on subcortical white matter of left frontal lobe and left temporal lobe which high signal intensity on T2-weighted image in the subcortical white matter of left frontal lobe (30×22 mm) and temporal lobe (24×20 mm), on coronal view (left) and transverse view (right). (B) Brain CT on hospital day 91. Ring like enhanced lesion with calcification in left frontal lobe (34×22 mm) and temporal lobe (28×19 mm) with enlargement of primary mass and progression of brain edema. (C) Brain CT After 20 months of anti-tuberculosis treatment, residual low density is in left frontal subcortical white matter without enhancement.

Mentions: After 26 days of admission, the culture of transtracheal aspirate on MGIT 960 medium yielded M. tuberculosis, was sent to the laboratory for rapid drug resistance assay and conventional drug sensitivity test of absolute concentration method by The Korean Institute of Tuberculosis [4]. On hospital day 31, rapid drug resistance assays by GenoType MTBDRplus turned out to be resistant to both INH and RFP with katG gene and rpoB gene mutation [5]. Administration of these drugs was stopped, and amikacin and moxifloxacin were added to the treatment regimen [12]. Chest radiography showed marked improvement (Fig. 1B). Meanwhile, on hospital day 34, she developed fever over 40℃ again, and a headache with increasing intensity. The cerebrospinal fluid (CSF) analysis showed white WBC count of 350/mm3 with 91% neutrophils and 8% lymphocytes, red blood cell count of 540/mm3, protein of 162 mg/dL, glucose of 35 mg/dL, and adenosine deaminase (ADA) level of 14.1 u/L. TB-PCR and AFB culture of CSF were negative. Magnetic resonance imaging of the brain showed high signal intensity on T2 weighted image with enhancement consistent with tuberculomas (Fig. 3A). After administration of the dexamethasone 0.4 mg/kg, the headache subsided. The follow up CSF was analyzed after 10 days, showing WBC count of 6/mm3, red blood cell count of 3/mm3, protein of 57 mg/dL, glucose of 44 mg/dL, and ADA of 13.5 u/L. The dexamethasone was tapered over 4 weeks.


A Case of Disseminated Multidrug-Resistant Tuberculosis involving the Brain.

Jung EK, Chang JY, Lee YP, Chung MK, Seo EK, Koo HS, Choi HJ - Infect Chemother (2016)

(A) Brain magnetic resonance image (MRI) on hospital day 31 showed brain edema and lesions on subcortical white matter of left frontal lobe and left temporal lobe which high signal intensity on T2-weighted image in the subcortical white matter of left frontal lobe (30×22 mm) and temporal lobe (24×20 mm), on coronal view (left) and transverse view (right). (B) Brain CT on hospital day 91. Ring like enhanced lesion with calcification in left frontal lobe (34×22 mm) and temporal lobe (28×19 mm) with enlargement of primary mass and progression of brain edema. (C) Brain CT After 20 months of anti-tuberculosis treatment, residual low density is in left frontal subcortical white matter without enhancement.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4835434&req=5

Figure 3: (A) Brain magnetic resonance image (MRI) on hospital day 31 showed brain edema and lesions on subcortical white matter of left frontal lobe and left temporal lobe which high signal intensity on T2-weighted image in the subcortical white matter of left frontal lobe (30×22 mm) and temporal lobe (24×20 mm), on coronal view (left) and transverse view (right). (B) Brain CT on hospital day 91. Ring like enhanced lesion with calcification in left frontal lobe (34×22 mm) and temporal lobe (28×19 mm) with enlargement of primary mass and progression of brain edema. (C) Brain CT After 20 months of anti-tuberculosis treatment, residual low density is in left frontal subcortical white matter without enhancement.
Mentions: After 26 days of admission, the culture of transtracheal aspirate on MGIT 960 medium yielded M. tuberculosis, was sent to the laboratory for rapid drug resistance assay and conventional drug sensitivity test of absolute concentration method by The Korean Institute of Tuberculosis [4]. On hospital day 31, rapid drug resistance assays by GenoType MTBDRplus turned out to be resistant to both INH and RFP with katG gene and rpoB gene mutation [5]. Administration of these drugs was stopped, and amikacin and moxifloxacin were added to the treatment regimen [12]. Chest radiography showed marked improvement (Fig. 1B). Meanwhile, on hospital day 34, she developed fever over 40℃ again, and a headache with increasing intensity. The cerebrospinal fluid (CSF) analysis showed white WBC count of 350/mm3 with 91% neutrophils and 8% lymphocytes, red blood cell count of 540/mm3, protein of 162 mg/dL, glucose of 35 mg/dL, and adenosine deaminase (ADA) level of 14.1 u/L. TB-PCR and AFB culture of CSF were negative. Magnetic resonance imaging of the brain showed high signal intensity on T2 weighted image with enhancement consistent with tuberculomas (Fig. 3A). After administration of the dexamethasone 0.4 mg/kg, the headache subsided. The follow up CSF was analyzed after 10 days, showing WBC count of 6/mm3, red blood cell count of 3/mm3, protein of 57 mg/dL, glucose of 44 mg/dL, and ADA of 13.5 u/L. The dexamethasone was tapered over 4 weeks.

Bottom Line: However, her headache and brain lesion worsened.Linezolid was added to intensify the treatment regimen, and steroid was added for the possibility of paradoxical response.Kanamycin was discontinued 6 months after initiation of the treatment; she was treated for 18 months with susceptible drugs and completely recovered.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea.

ABSTRACT
We report a case of a 23-year-old female immigrant from China who was diagnosed with multidrug-resistant tuberculosis affecting her lung and brain, resistant to the standard first-line therapeutics and streptomycin. She was treated with prothionamide, moxifloxacin, cycloserine, and kanamycin. However, her headache and brain lesion worsened. After the brain biopsy, the patient was confirmed with intracranial tuberculoma. Linezolid was added to intensify the treatment regimen, and steroid was added for the possibility of paradoxical response. Kanamycin was discontinued 6 months after initiation of the treatment; she was treated for 18 months with susceptible drugs and completely recovered. To our knowledge, this case is the first multidrug-resistant tuberculosis that disseminated to the brain in Korea.

No MeSH data available.


Related in: MedlinePlus