Discussion:
In this study, a TBM patient with NCSE is reported. The frequency of status epilepticus in TB patients is 7.6%.(9)  However, to the best of our knowledge, only 4 cases of TBM presenting with NCSE have been reported in the literature (11-14). Seizures are reported in 50-73% of children, and 10-38% of adults in the clinical course of TBM (15-17).
Both febrile and afebrile seizures can be the presenting feature of TBM in children. The frequency of status epilepticus in TBM patients is 7.6%. It is reported that Convulsions are a significant predictor of mortality (18). Our patient presented with altered level of consciousness and unresponsiveness and persistent seizure activity on the EEG that comprised 1 to 2-Hz continuous sharp and slow wave activity. Inconsistent with our study, a study by Arman study et al. (11) has reported a patient with NCSE due to tuberculosis meningitis who had right frontal 1.5- to 2-Hz continuous focal sharp and slow waves. In contrast in Oka study et al. (13), EEG showed left frontal 2.5- to 3-Hz repetitive focal sharp wave activity compatible with NCSE.
Continuous epileptiform EEG activity in NCSE is expected to be higher than 2.5 Hz, whereby when epileptiform discharges are less than 2.5Hz, one out of three other criteria is needed to confirm the diagnosis of NCSE including presence of mini-convulsive signs, evolution in amplitude or frequency of discharges and responsiveness to intravenous administration of benzodiazepines (19). Our patient had no mini-convulsive signs but she had an obvious response to intravenous diazepam and levetiracetam, both clinically and electrically. The patient in Arman study et al. (11) responded to diazepam and phenytoin, followed by midazolam infusion. In Oka study et al. (13) after anticonvulsant treatment with levetiracetam, persistent EEG activity ceased with the recovery of consciousness
In our study, recovery of consciousness and normalization of subsequent EEGs with antiepileptic therapy have happened. A study by Kalita et al. (19) on the 32 patients with highly probable tuberculous meningitis have done. Evidence of extra-CNS tuberculosis were present in 6 patients; all had pulmonary tuberculosis. The main abnormality in their EEG was diffuse slowing of the background activity (69%).
Our patient had diffused sharp and wave activity with slow background which is compatible with status epilepticus (20). Several reports establish that 84% of CNS tuberculoma clearly showed low signal on T2- weight images and 16% had lesions with central high signal thought to represent caseating necrosis or tuberculous abscesses (21-23).
At an early stage of tuberculoma formation, the mass is isointense on T1- and T2-weighted images and shows some contrast enhancement, that is secondary to occurrence of inflammatory reactions and excess of giant cells in the mass and a poor collagen capsule, that it becomes rich in collagen, later in the course of disease. They give low signal on T2-weighted images because of fibrosis, scar tissue (24). Rarely, tuberculomas show calcification on CT, but it can appear as low signal on MRI. All tuberculomas show ring or nodular contrast enhancement.
Almost one third of tuberculomas are multiple (25). Various differential diagnosis should be considered in a patient presented with altered level of consciousness and multiple ring-enhancing lesions, especially neoplasms either metastasis or primary lymphoma and other infectious diseases like fungus or bacterial endocarditis. Moreover, Tuberculomas have a variety of different features that can mimic other space-occupying lesions, such as neoplasms.
Metastases, multiple gliomata or meningiomas excluded by further evaluations. No space occupying lesion was found in the chest and abdominopelvic CT-scan. The pathology of her surgery was in favor of diffuse granulomatous involvement.
The normal CSF glucose and protein levels are unusual but not incompatible with the diagnosis of TB (26). Acid-fast bacilli are seen in only 40% cases on initial CSF examination (27). The tuberculin test is negative in 50% cases at presentation (28). Similar to Arman study et al. (11) in this study, PCR of CSF was negative, but nested PCR assay was positive. Nested PCR is a technique that reduces nonspecific amplification of the DNA template. It increases the sensitivity and specificity of the reaction and is useful on suboptimal nucleic acid samples (29).
The presence of a low signal lesion on T2-weighted images that shows ring or nodular contrast enhancement in a patient who has tuberculosis elsewhere in the body and from a region in which tuberculosis is endemic should suggest CNS tuberculoma.
The patient’s clinical findings, unexplained acute change of consciousness, together with chest involvement, diffuse granulomatous infiltration in uterus and ovaries, and multiple ring enhancement lesions in brain MRI, led to the diagnosis of TBM. The positive response of the patient to antituberculosis treatment also supported the diagnosis.