Tuberculous meningitis masquerading as acute ischemic stroke in young adult

Tubercular meningitis (TBM) constitute 5% of all cases of extra pulmonary tuberculosis but a presentation leading to an ischemic stroke in a young adult is a rare clinical entity. In a case of TB vasculopathy, vasculitis, venous thrombosis and aneurysm may be the underlying events leading to a stroke. Stroke in TBM is seen in the tubercular zone which encompasses internal capsule, thalamus and caudate nucleus. Inflammatory mediators like TNF alpha, Interferon gamma and vascular endothelial growth factor have been implicated in the pathogenesis of arteritis. Imaging modalities like MRI show lesions which are usually bilateral in the territory of the perforating vessels. We report a case of 24 year old Asian male who presented with complaints of headache, projectile vomiting and altered sensorium. On examination his Glasgow Coma Scale (GCS) was 10/15, with left oculomotor and left facial nerve palsy, and hypotonia of all 4 limbs with bilateral plantar reflexes being mute. Contrast MRI of brain showed acute infarct, meningeal enhancement and basal exudates. He was started on Anti-tubercular therapy and steroids, but had a poor clinical outcome, due to his late presentation.

Pattern of HIV infected meningitis patient investigated in a tertiary care institute of eastern India

Background: This study was started in the aim of determining the pattern of meningitis and their clinico-laboratorial presentation among HIV infected patients.Methods: This secondary data based cross-sectional study was conducted on 2010 in a tertiary care institute of eastern India among HIV infected meningitis patients. From June 2009 to May 2010, 92 patients were included in our study. Bed head tickets, laboratory reports and registers were used for data collection. Chi square test was applied for the test of significance.Results: 70.7% cryptococcal and 29.3% tubercular meningitis cases were found. Mean CD4 cell count, CSF protein, CSF glucose, WBC cell count of TB and cryptococcal meningitis patients were 143 cells/cumm, 546.1 mg/dl, 26.8 mg/dl, 550 cells/ cumm and 175 cells/ cumm, 189.1 mg/dl, 30.1 mg/dl, 36 cells/ cumm respectively. 29.2% patients of Cryptococcal meningitis were presented with mental change, confusion or psychological disorders, but these symptoms were not observed among TB meningitis patients.Conclusions: This study provided a baseline data about epidemiology and clino-laboratorial features of HIV meningitis patients of eastern India and will help for further investigation in this field.

MODS Culture for Primary Diagnosis of Tuberculous Meningitis and HIV-Associated Pulmonary Tuberculosis in Indonesia.

Aims: To compare the microscopic observation drug susceptibility (MODS) culture with microscopy and solid culture for diagnosis of TB meningitis and HIV-associated pulmonary tuberculosis (TB). Study Design: Comparative study. Place and Duration of Study: Department of Clinical Pathology, Hasan Sadikin Hospital, Bandung, Indonesia, between 2010 and 2012. Methodology: Two groups of patients were included. The first group consisted of 167 consecutive HIV-infected patients presenting with suspected pulmonary TB. The second group consisted of 88 patients with clinical suspicion of TB meningitis. Sputum samples from HIV-associated pulmonary TB patients and cerebrospinal fluid (CSF) from patients with TB meningitis were analyzed using microscopy of Ziehl-Neelsen (ZN) stained smears, culture on solid medium (Ogawa), and MODS culture. Results: MODS showed the highest detection rate in both patient groups. Among HIV-associated pulmonary TB patients, positivity of MODS was 31.2% compared with 26.9% for Ogawa and 20.6% for ZN. Among TB meningitis patients, positivity of MODS was 41.2% compared with 38.8% for Ogawa and 8.3% for ZN. The median time to culture positivity was significantly shorter for MODS compared to Ogawa, both for sputum (median 11 vs 21 days) and CSF (14 vs 33 days). In 14 days, MODS detected significantly more cases compared with Ogawa in both patients group (79.2% vs 2.4% and 68.6% vs 0%, respectively). Laboratory staff readily used MODS after two weeks of training. Conclusion: We were able to implement MODS culture as a robust, sensitive, and rapid method for diagnosis of HIV-assoicated pulmonary TB and TB meningitis in a hospital setting in Indonesia. Further studies may be needed to assess the feasibility of MODS culture in other settings and assess its impact on case detection and timely treatment of both forms of TB.

Streptomycin in tuberculosis meningitis with reports of forty cases

1) 40 out of 125 cases of T.B meningitis given streptomycin therapy are reported2) 20 died and 20 are still living. Of the last group, 10 have had a long remission ranging from 18 months (the longest) to 6 months (the shortest). All of the 20 cases are now symptom free3) The average dose of streptomycin given intramuscularly was 74.2 mg. per kilo per day. The dosage of intrathecal injection ranged from 25 mg. to 200 mg per injection, with an interval ranging from 2 days to 2 weeks4) 5 cases did not receive the drug intracthecally. They are all still living. No definite conclusion can be made whether intrathecal injection together with intramuscular administration is better than intramuscular injection alone. In our limited experience, intramuscular injection alone produces less toxic symptoms than the combined intrathecal and intramuscular injections5) Skin rashes, fever, edema and ataxia were the toxic manifestations of the drug frequently observed by us6) It appears justifiable to conclude that streptomycin can prolong and modify the course of T.B. meningitis. (Summary)