Case Presentation:
A 50-year-old Iranian woman was admitted to our hospital with an exacerbation of abnormal uterine bleeding (AUB) for total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO). Her history revealed 10Kg weight loss during previous 3months, anorexia, night sweets, nausea, vomiting and several episodes of fever and cough,for which she hasn’t seek any treatment. She had suffered primary biliary cirrhosis (PBC) since 1999 and had been treated with ursodeoxycholic acid (750 mg daily) without any immunosuppressive therapy. She had no significant history of pulmonary or genital tuberculosis. She had given birth to a son and a daughter. During her admission for TAH-BSO surgery she had fever. The spiral chest CT-scan showed bilateral pleural effusions without lymph node swellings with diffuse ground-glass opacities and small centrilobular nodules. Sputum acid-fast bacilli was positive and anti-TB treatment with isoniazid, rifampicin, ethambutol and pyrazinamide was started. One day after TAH-BSO surgery, she presented with acute alteration of mental status manifested with impairment of awareness, disorientation to time, place and person and bizarre behavior like undressing herself and urination in the ward. Next day she became completely unresponsive, while she was fully awake. So, she underwent neurology and psychiatry consult in the same day as it was thought to have a psychiatric origin, as well.
Examination at presentation revealed no meningeal irritation, absent neck stiffness, Kernig’s and Brudzinski’s signs with mental alterations in the form of unawareness and unresponsiveness. The patient was afebrile. Fundoscopy was normal with intact cranial nerves. Deep tendon reflexes were elicited and plantar reflexes were flexor. Neurological tests requiring cooperation such as cerebellar tests, muscle strength examinations, and sensorium were not performed as she ignored commands, but she moved her limbs symmetric in the bed, without any convulsive or mini convulsive signs.
On initial presentation, routine blood tests revealed a normal white blood cell count of 8,700/mm3, low erythrocyte count of 3,630,000/mm3 and hemoglobin level of 8.3 g/dL, high C-reactive protein level of 95 mg/L (normal: <6), glucose level of 190 mg/dL and low sodium level of 130 mmol/L. She had negative results for human immunodeficiency virus. Other laboratory findings had no remarkable changes.
cerebrospinal fluid (CSF) was taken immediately after neurology consult, which is about a weak after initiation of treatment for TB. The opening pressure was 25cmH2O, the leukocyte count was 0/μL, the protein level was 36.1 mg/dL, and the glucose level was 57 mg/dL (corresponding blood glucose level, 130 mg/dL). Tuberculous DNA polymerase chain reaction (PCR) of CSF showed negative results, but nested PCR assay yielded a positive result. Adenosine deaminase level was 32.4 IU/L (normal <10 IU/L).
The EEG showed generalized 1.5- to 2-Hz continuous sharp and slow wave activities. (figure 1), that had improved significantly after administration of diazepam (figure 2) and after antiepileptic treatment significant improvement in EEG trace is seen together with normal alpha background and correction of periodic discharge waves (figure 3).
Magnetic Resonance Imaging (MRI) of the brain revealed multiple lesions which were iso signal in T1 and low signal at center in T2, with ring enhancement in supra and infratentorial regions of both hemispheres, at the subcortical, white-gray matter junction. Some of them had nodular enhancement, with moderate vasogenic edema around lesions. All of the findings in the context of clinical features were in favor of TB (figure 4).
The patient was diagnosed as having TBM presenting with NCSE, and treatment was started for NCSE. The protocol for treatment of status epilepticus comprised diazepam and levetiracetam infusion, and then treatment with the oral antiepileptic drugs. Anti-TBM treatment consisted of four anti-tuberculosis drugs continued. The patient’s consciousness and clinical picture improved completely after the loading dose of levetiracetam and she became entirely aware and oriented. Her follow-up EEG improved significantly. No reoccurrence of cognitive decline happened.