Introduction:
Nonconvulsive status epilepticus (NCSE) is a serious epileptic condition in which there is minimal or no motor activity. Electrical activity in NCSE is continuous, lasting at least 30 minutes and leads to changes in mental or behavioral status (1, 2). NCSE is relatively common and constitutes 20–25% of all status epilepticus cases (3). It is often difficult to diagnose NCSE, as there is minimal or no objective convulsive activity and many other conditions can change the mental status in predisposing conditions of NCSE. The underdiagnosis may lead to detrimental results (4).
Treatment can be delayed as mental status changes without obvious convulsions. Treatment is not simple and depends on many factors, including the etiology, electroencephalogram (EEG) findings, and the patient’s clinical condition(3). Etiologies include idiopathic epilepsy syndrome, metabolic disorders, trauma, brain tumors, cerebral hypoxia, and infectious diseases (5).
Tuberculous meningoencephalitis (TBM) compromise 1% of all TB cases (6). It is a life-threatening form of central nervous system infection, with significantly higher mortality and neurological impairment among infected people. TBM has a subacute onset of symptoms with non-specific clinical signs that may persist for weeks, often making early diagnosis difficult. It is characterized by fever, headache, vomiting, focal neurological signs or coma (7).
Seizures have been reported in 17% to 93% of patients with TBM (8). The seizures in TBM can be either focal or generalized tonic-clonic seizure and convulsive or non-convulsive status epilepticus (9). The etiology of TBM seizures is multifactorial and has been identified independently or in combination due to meningeal irritation, cerebral edema, tuberculoma, infarction, hydrocephalous and hyponatremia. Seizures in TBM can occur during the active phase or as sequel of meningitis. It can even be the characteristic of CNS tuberculosis (heraldic seizure) in 10% of all patients (10).
Here we report a rare presentation of TBM where the patient presented with NCSE and tuberculous meningitis. This case highlights the importance of clinicians’ awareness on unusual clinical presentations of TBM, because NCSE is hard to diagnose without having it constantly in mind and delayed diagnosis is associated with a poor prognosis.