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.