Tuberculous meningitis with thalamus infarction

Objectives: Because of increase of tuberculous diseases, seldom complications of tuberculosis will become more frequent. We report about a patient with tuberculous meningitis and only mild pulmonary symptoms.

Material and Methods: A 5 year old patient, daughter of a German mother and an Vietnamese father, had four weeks before admission to hospital a slight pulmonary infection which was treated with clarithromycine. On the day of admission she suffered from fever and signs of meningitis.

The lumbar punction showed typical results with CSF pleocytosis (396 leucocytes/µl), elevated protein (78mg/dl), clearly reduced glucose concentration (24mg/dl; blood glucose: 97mg/dl), and an intrathecal synthesis of immunoglobulins with predominant IgA synthesis. The isolation of M. tuberculosis was unsuccessful. The PCR in CSF was negative. The cerebral MRI was normal. The chest X ray showed a primary complex in the left lung.

Results: We started tuberculostatic treatment with rifampicine, pyrazinamide, isozianide and streptomycine. In addition a dexamethason therapy for 6 weeks was given. The MRI control on the 29th day of treatment showed typical signs of a basal meningitis. Clinically there was no involvement of cranial nerves. A second control of the cerebral MRI on the 50th day of treatment showed postischaemic defects in the thalamus. The parameters of coagulation revealed an elevated lipoprotein a. After 8 weeks of treatment the patient was released from the hospital without any remaining symptoms.

Conclusions: Even without typical pulmonary symptoms but with typical CSF examination results one should take a tuberculous meningitis into consideration. The development of cerebral perfusion defects is a typical complication of tuberculous meningitis, which may develop later in the clinical course.