(492) Tuberculous Meningitis: A Rare Presentation Without Evidence of Seeding or Reactivation

Introduction: Mycobacterium tuberculosis can involve multiple organs including lung, liver, kidney, brain, and bone. However, one of the more uncommon sites of infection are the meninges leading to tuberculous meningitis (TBM) which is occasionally described in literature. Meningeal infection is usually due to seeding from the primary infection or chronic reactivation. We present a case of tuberculous meningitis without evidence of seeding or chronic reactivation.

Description: A 23-year-old male with no reported past medical history presented with headaches, arthralgias, and fever after testing positive for COVID-19. Patient had no recent travel or sick contacts, and had never previously been diagnosed with TB. Physical exam was significant for neck pain, nuchal rigidity, and photophobia, without rash or lymphadenopathy. Complete blood count was unremarkable, complete metabolic panel was notable for a hyponatremia 125 mEq/L, and elevated LFTs with AST and ALT being 243 U/L and 406 U/L respectively. Head CT, head MRI, chest x-ray, lumbar spine MRI, and CT abdomen/ pelvis were negative for acute findings. Patient was admitted to the intensive care unit due to worsening encephalopathy. Lumbar puncture was performed with an opening pressure of 43 cmH2O, total protein of 140 g/L, glucose of 20 mmol/L, 412 nucleated cells, with 92% neutrophils, and 4% lymphocytes. Patient was treated empirically for bacterial meningitis with ceftriaxone, ampicillin, vancomycin, and dexamethasone. Cerebral spinal fluid was positive for Acid-Fast Bacillus, and Mycobacterium tuberculosis complex reported on final culture. RIPE therapy was initiated and the patient improved. Patient was subsequently transferred out of the intensive care unit for continuation of care.

Discussion: Every year it is estimated that 10 million people contract TB, with 1.6 million dying of infection each year. TBM is found within 1% of extrapulmonary cases, with as high as 10% in high TB–burden countries. In the adult population, TBM is mostly described as a chronic reactivation of previous disease state due to recent immunosuppression. This case however shows an extremely rare presentation of TBM without evidence of primary infection seeding the meninges, history of TB infection, recent travel, or immunosuppressive conditions.