Central Nervous System Tuberculosis with SARS-CoV-2 Infection: A Short Case-series from Sri Lanka

ABSTRACT

Objective: To report a series of patients with clinical and imaging findings suggestive of central nervous system (CNS) Tuberculosis (TB) and active or recent SARS-CoV-2 infection presenting to a single tertiary care center within a two-month period. Background: A presumptive diagnosis of CNS TB is made in the setting of relevant clinical and epidemiologic factors together with typical radiographic findings. Immunosuppression is clearly associated with reactivation or re-infection of TB, although triggers leading to a reactivation are unclear. It is postulated that the SARS-CoV-2 infection suppresses the host innate and adaptive immunity. Design/Methods: NA Results: Three patients with suspected and one with confirmed CNS TB were identified. Patient one presented with a history of fever and altered sensorium for one-week. Concurrent SARS-CoV-2 infection was confirmed. CT-brain showed an obstructive hydrocephalus and an External Ventricular Drain was placed. Cerebrospinal fluid (CSF) nucleic acid amplification test (NAAT) for TB was positive. Patients 2-4 were diabetic and had SARS-CoV-2 infection identified concurrently or in the preceding two weeks. They presented with a history of headache & diplopia of two weeks duration. Examination revealed multiple cranial nerve palsies. The common MRI features were contrast enhancement & soft tissue thickening in the cavernous sinus wall. Patient two had multiple tuberculomas, patient three had orbital apex involvement and patient four had Meckel's cave thickening. CSF analysis revealed elevated proteins without cells and NAAT for TB was negative. All patients were started on anti-TB chemoprophylaxis with corticosteroids. Conclusions: Given the potential immunomodulatory role of SARS-CoV-2, we hypothesize that the viral infection acted as a trigger for the reactivation of TB in the CNS. In addition, three out of four of our patients had cavernous sinus wall involvement which is an unusual finding in CNS TB.