ABSTRACT
We report a rare case of oculomotor nerve palsy and choroidal tuberculous granuloma associated with tuberculous meningoencephalitis. A 15-year-old male visited our hospital for an acute drop of the left eyelid and diplopia. He has been on anti-tuberculous drugs (isoniazid, rifampin) for 1 year for his tuberculous encephalitis. A neurological examination revealed a conscious clear patient with isolated left oculomotor nerve palsy, which manifested as ptosis, and a fundus examination revealed choroidal tuberculoma. Other anti-tuberculous drugs (pyrazinamide, ethambutol) and a steroid (dexamethasone) were added. After 3 months on this medication, ptosis of the left upper eyelid improved and the choroidal tuberculoma decreasedin size, but a right homonymous visual field defect remained. When a patient with tuberculous meningitis presents with abrupt onset oculomotor nerve palsy, rapid re-diagnosis should be undertaken and proper treatment initiated, because the prognosis is critically dependent on the timing of adequate treatment.
Subject(s)
Adolescent , Humans , Male , Antitubercular Agents/therapeutic use , Blepharoptosis/diagnosis , Choroid Diseases/diagnosis , Dexamethasone/therapeutic use , Drug Therapy, Combination , Ethambutol/therapeutic use , Glucocorticoids/therapeutic use , Magnetic Resonance Imaging , Meningoencephalitis/diagnosis , Mycobacterium tuberculosis/isolation & purification , Oculomotor Nerve Diseases/diagnosis , Visual Field Tests , Pyrazinamide/therapeutic use , Radiography, Thoracic , Tuberculoma/diagnosis , Tuberculosis, Meningeal/diagnosis , Tuberculosis, Ocular/diagnosis , Visual FieldsABSTRACT
This study assessed 231 cases of tuberculous meningitis of which 62 (26.8%) had diagnostic confirmation against 169 (73.2%) with only clinical picture and laboratorial indication for this diagnosis. Fifty-five percent of the sample was male; ages ranged from one month to 68 years, 42% comprising children below four years. Clinical, demographic and liquoric characteristics were investigated and compared amongst those with likely and confirmed diagnosis. In conclusion, attention is drawn to the severity of this disease with high rates of lethality mainly within the age-range of 0-4 years, and to the possibility of misdiagnosis in the presentation of acute forms and predominance of neutrophils in the liquor.
Neste estudo foram avaliados 231 pacientes com meningoencefalite tuberculosa, sendo que 62 casos tiveram diagnóstico comprovado e 169 apresentavam quadro clínico e laboratorial compatíveis com este diagnóstico. Foram 127 (55%) pacientes do sexo masculino, a idade variou de 1 mês a 68 anos, com 97 (42%) na faixa etária igual ou inferior a um ano. As características clínicas, demográficas e liquóricas foram estudadas e comparadas entre os casos confirmados e os de diagnóstico provável. Em conclusão reafirmamos a gravidade desta doença, com altas taxas de letalidade principalmente na faixa etária de zero a quatro anos e a possibilidade de erros diagnósticos nas apresentações com formas agudas e predominância de neutrófilos no líquor.