1. An interesting case of Tuberculosis
DevendraPatil
Dr. Prof. Magheshkumar Unit
M1 unit

2. We sincerely thank
Dr.Chenthil ( IMCU chief )
Dr. Gowrishankar and M3 team
Dept of Neuro-Surgery
Departmentof chest medicine
Endocrinology dept, SMF
Apollo Hospital Labs
3. Case history
A 21 year old unmarried girl came to GSH with chief complains of
Fever ( low grade, evening rise)..10 days
Altered behavior..4 days
Increased drowsiness.3 days
4. No h/o
convulsions
Neck pains , headache , vomiting
Fall/trauma to head
Weakness in any on the limbs , diplopia
Cough with expectoration
Abdominal pains
Join pains / swelling
Body rash
Swellings in neck , axilla , groin
Jaundice in past
TB in past / family
5. o/e
She is drowsy , responding to painful stimuli ,
GCS 10/15
Temp 100 F
P- 94 /min regular
RR 16 / min regular
BP 130/80 mm Hg
No pallor / ict / cyn /club / LN / pedal oedema
Neck veins normal
Skin -normal
No external markers ofTB
CVS :NAD
RS : NAD
PA :NAD
6. CNS
Higher mental function
Drowsy
Disoriented
Responding to painful stimuli
Cranial :
Pupils B/L equal reacting to light
Fundus : b/l normal, no e/o papillodema
no other cranial nerve involvement
Spinomotor:tone is normal in all 4 limbs
power is 3+/5 in all limbs
all DTR are present and normal
B/L plantar - flexor
Sensory : response to pain present,
Cerebellar : no signs present
Meningeal : neck rigidity +nt
Kernigs ve , Brudzinki ve
Skull and spine- normal
7. Problems
Subacute fever
Altered behaviour
Neck rigidity
8. Working Diagnosis :
CNS infection
- TB
- cerebral malaria
- bacterial meningitis
- aseptic meningo enephalitis
Plan:
Baseline investigations
IMCU care
Empirical treatment for CNS infection
CSF analysis
Neuro-imaging
Steroid dose
9. Investigation
Hb 9.8 gm%
TC 5600/cc
DC P56,L32
ESR 22mm/hr
Platelet 2.3 lac
RBS 84 mg%
Urea 21 mg%
Cr 0.7 mg%
Na 139 meq/L
K 3.7 meq/L
CSF analysis :
Physical : clear
Pressure : high ( not measured )
Protein : 140 mg%
Sugar -34 mg %
Cells -8-10 lymphocytes seen
ADA -7 IU/L
Cytology lymphocytes seen
Grams Stain - negative
AFB stain negative
PCR ( MTB ) not sent
IMPRESSION :
Suggetsive of TB meningitis
10. NEUROIMAGING
What to expect in a case of TB meningitis ?
Infarcts ( due to vascuitis )
Granuloma
Arachnoiditis
Subpial / subependymal foci of TB
Ependimitis
Leptomenigealenchancement
Exudation
Choriodplexitis
Hydrocephaleus
11. 12. 13. 14. 15. 16. 17. 18. 19. Neuro imaging
CT Brain : Normal study
MRI BRAIN :
Right thalamus infarct
Pontine , occipital , parietal SOL
Ring enhancement present
Lepto-meningeal enhancement
Occiptal exudates
f/s/o--- CNS tuberculosis
20. ATT registration and commencment
Antibiotic policy changed
Steroids continued
Patient general condition improved
Shifted to ward and accordingly discharged
She was asked to continue ATT at nearby DOTS centre
21. 5 months later.
She came with chief complains of
Secondary Amenorrhea .. 5 months
Excessive Weight gain .. 5 months
Altered behaivour ..2 weeks
Drowsiness , Headache , Vomiting
Excessive sleepiness. 2 weeks
22. O/e
She is drowsy , responding to oral stimuli ,
T- afebrile
P 86 /min
RR- 14 / min
BP 100/70 mm Hg
No pallor / icterus / cyn /club /nodes
Facial puffiness seen
Decreased frequency of urination
No pedal edema
CVS - NAD
RS - NAD
PA - NAD
23. CNS :
Higher mental function:
Drowsy
Not oriented
Responding to painful stimuli
CRANIAL NERVES:
Pupils B/L equal reacting to light.
no ophtalmoplegia
no papillodema
No other cranial nerve involvement
SPINOMOTOR : tone and reflexes were normal
SENSORY : pain sensation preserved
Meningeal : neck stiffness present
Kernig sign - absent
Cerebellar :couldnt be assessed
Spine , Skull -normal
24. Problems
c/o TB meningitis on ATT since 5 months
Non compliance
Incomplete steroid treatment
Meningeal signs
Secondary Amenorrhea
Altered behaivour
Weight gain with reduced urine frequency
25. Possibility
TB relapse
TB Hydrocephalus
Hyponatremia
Chronic meningitis of different etiology
26. Investigation
Hb 10 gm %
TC 6500 /cc
DC P60,L35
ESR 25 mm/hr
Platelet 1.2 lac
RBS-90 mg%
Urea 27 mg%
Cr-0.6 mg%
Na- 124 meq/L
K 3.6 meq/L
CSF analysis :
Physical-clear
Pressure high ( not measured )
Protein -120 mg %
Sugar -29 mg%
Cells -few lymphocytes
ADA not sent
Cytology- acellular
Grams Stain - negative
AFB stain negative
Impression :
Suggestive of TB meningitis
Or incompletely treated pyogenic meningitis
27. On the 3rd day of re-admission patient developed precipitous neurological detoriationand complained on binocular diplopia
Causes:
Cerebral edema
Hyponatremia
Raised ICT
hydrocephalus
She was given iv. mannitol and iv. steroids
An emergency CT brain was requested and promptly done.
28. 29. 30. An emergency call - over to neuro surgery dept was given and they took over the patient for an immediate ventricular decompression surgery.
Post surgery patient recovered
Became more responsive and there was a dramatic reduction in the facial and pedal odema.
Patient was shifted back to medicine wards 10 days later.
31. 32. 33. Siadh
There is a strong suspicion that part of the delirium in our patient could be due to SIADH secondary to CNS tuberculosis and the ensuing communicating hydrocephalus
The points that are in favour are
Hypo-osmolarHyponatremia
Reduced urinary frequency
Urine 24 hr Na+ levels916 meq/L
Altered behaivour
Clear-cut etiology
brisk diuresis following relief of hydrocephalus
pt lost weight and became as she was about 5 months back
However the points not in favour are :
Presence of f/s/o overhydrated state
Urine osmolality studies not done
34. Problems that were still persisting
Patient still drowsy
Prefered to sleep most of the day
Reduced appetite
Secondary Amenorrhea
Lower range of BP
Generalised apathy to surroundings
35. Possibilities
VP shunt malfunction / blockade
Hyerprolactinemia
TB of genitourinary tract ( hypogonadism )
Plan :
Neurosurgical review
Gynacological opinion
Neurological opinion
Repeat electrolytes
36. Neuro surgical opinion: nil active currently
shunt working
Gynecological opinion:
Urine pregnancy test negative
USG Abdomen and pelvis normal study
T. Megestrol for withdrawl bleeding
37. Thyroid profile
In v/o increased weight and listless behaivour
Free T3 -2.3 (2.4 4.2 pg/dl)
Free T4 -0.6( 0.8 1.7 ng/dl)
TSH 0.2 ( 0.4 4.0 IU/l)
Impression : hypothyroidism secondary
38. 39. 40. 41. Prolactin fasting : 40 ug/L ( 0-20)
S. cortisol 8a.m. fasting 6.9 ug/L ( 8-25)
S. LH-- 0.1 uIU/L ( 2-15)
S. FSH--0.2UuIU/L ( 3-26)
Impresssion:
Mildly elevated prolactin
Hypogonadotropichypogonadism
Hypocortisolism
Secondary hypothyroidism
42. Possibilites:
TB of the pituitary gland
TB exudation causing Hypothal pituitary axis supression ( stalk section effect )
Further plan:
MRI imaging of the pituitary gland
43. neuroimaging
44. 45. 46. 47. 48. 49. 50. Treatment given:
ATT under cat 1 to be continued
Repeated counselling regarding the compliance
T. Eltroxin 50 ug/day
T. Hydrocort20mg/8am and 10 mg/8pm
T. Estrogen
T. Progesterone
Her condition improved to an extent that she was able to do her work independently.
51. Final Diagnosis
TB chronic meningitis
Sequaelae
Communicating hydrocephaleus
VP shunt in situ and functioning
anterior - Hypopitutarism
Pituitary tuberculosis
On hormone replacement therapy
52. What is so different in this case
The propensity of TB to affect the pituitary is rare.
53. What is so different in this case
The lesion is primarily in the pitiutary or the hypothalamus is quite uncertain.
54. Why a ACTH stimulation and GHRH stimulation test not done
55. Why was a PCR not done
56. Most of the case reports have a histopathological diagnosis.
Hence a trans spenoidoidal biopsy should be done as an ultimate proof of the pathology
57. What is so different in this case
The development of clinically apparent TB hypopituitarism when the patient is already on ATT is puzzling.
58. KEY MESSAGE.
TB pituitary israre but known entity
Recent onset of altered behaivour , apathy , secondary amenorrhea especially in endemic regions should suggest possibility of tuberculous involvement of hypophysiscerebri.
It is important for us to keep a high index of suspicion in managing cases of CNS tuberculosis to pick up its complications very early in the course
59. Thank you
References :
Harrisons 16/e
Sharma tuberculosis
K Sunil, et.al.,Pituitary Tuberculosis. JAPI 2007.