Hemiparesis in Pediatric Tuberculous Meningitis: A Case Report

Sylvia Cahyadi

, Jeanette Marchi

, Rina Amalia Caromina Saragih

, Lesmana Syahrir

General Practitioner, Siloam Dhirga Surya Hospital, Jalan Imam Bonjol No 6 Medan. North Sumatera, Indonesia

Pediatric Emergency & Intensive Care Division, Child Health Department, Faculty of Medicine, Universitas Sumatera

Utara, Jl. Abdul Hakim No.1, Medan, North Sumatera, Indonesia

Department of Pediatrics. Siloam Dhirga Surya Hospital, Jalan Imam Bonjol No 6 Medan, North Sumatera, Indonesia

Keyword: Tuberculous meningitis, pediatric tuberculous meningitis, hemiparesis

Abstract: Tuberculous meningitis (TBM) can occur as the sole manifestation of tuberculosis (TB) or concurrent with

pulmonary or other extrapulmonary sites of infection. It causes high mortality and morbidity. Patients with

TBM develop typical symptoms and signs of meningitis. Cranial nerve palsies, hemiparesis, paraparesis,

and seizures are common and should raise the possibility of MTB as the etiology of meningitis. We present

a case of TBM in an 11-year-old who was admitted to High Care Unit Siloam Dhirga Surya Hospital,

Medan, Indonesia with a decreased level of consciousness, sudden weakness of a right extremity, headache,

nuchal rigidity, and history of fever and cough. Chest X-ray showed miliary TB and head CT scan showed

hydrocephalus. Laboratory results were leukocytosis, hyponatremia, and positive TB IGRA. The patient

was then treated with normal saline infusion, anti TB regimen, an antibiotic, and oral corticosteroid. With

regular admission of the anti-tuberculosis drug, oral corticosteroid, and physiotherapist, the patient showed

improvement in his motoric function. The clinical symptom of TBM may appear as hemiparesis without a

seizure. Proper treatment of tuberculous meningitis may lead to a better outcome.

1 INTRODUCTION

Indonesia has one of the highest burden of

tuberculosis (TB) globally (WHO, 2018). It is

estimated that childhood TB constitutes 10 to 20%

of all TB cases in high burden countries, accounting

for 8 to 20% of TB-related deaths. Approximately,

25% of pediatric TB cases are extrapulmonary, with

tuberculous meningitis (TBM) being the most severe

form. Worldwide, tuberculous meningitis (TBM)

accounts for the majority of the deaths due to TB

(Israni, et al., 2016).

Tuberculous meningitis may present at any age

but is less common at the extremes of life. The peak

incidence is in children between 2 and 4 years of

age. Most early symptoms relate to underlying

pulmonary TB present in most infants who develop

TBM as a complication of primary infection (Chin,

2014).

The most commonly recorded signs and

symptoms of TBM were an altered level of

consciousness (90.1%), meningism (77.2%), fever

(68.2%), and loss of appetite (61.4%). Focal

neurological signs included unilaterally non-reactive

pupils (13.6%), other cranial nerve palsies (22.7%),

limb paresis (27.3%), and aphasia (18.2%)

(Rohlwink, et al., 2016).

2 CASE PRESENTATION

An 11-year-old boy was admitted to the High

Care Unit (HCU) Siloam Dhirga Surya Hospital

with a decreased level of consciousness, headache,

and sudden weakness on the right extremities. The

patient had been hospitalized before with fever and

cough. There was a history of fever and cough for

two weeks and weight loss in one month. No history

of close contact with active TB patient, but his father

was suffering from chronic cough without receiving

any medication.

Physical examination revealed somnolence

(GCS 14), slurred communication, and normal

temperature. On neurological examination, there was

nuchal rigidity, clonus on the right extremities,

positive Babinski sign, and no muscle contraction in

the right extremities. No presence of seizure. The

chest was clear bilaterally.

Cahyadi, S., Marchi, J., Saragih, R. and Syahrir, L.

Hemiparesis in Pediatric Tuberculous Meningitis: A Case Report.

DOI: 10.5220/0009862801770179

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 177-179

ISBN: 978-989-758-469-5

177

Laboratory test showed leukocytosis (11.820

/mm

) with elevated of neutrophil (74.9%) and

Erythrocyte Sedimentation Rate (ESR). The patient

was hyponatremic (127 meq/L) and had positive TB

IGRA.

Chest X-ray showed miliary TB (Figure 1), and

the CT of the brain showed mild hydrocephalus

which suggests meningitis (figure 2 and figure 3).

Tuberculin test was negative (0 mm). The lumbar

puncture could not be performed technically.

Figure 1: Chest X-Ray.

Figure 2: Head CT scan shows mild hydrocephalus in the

third ventricle.

The patient was then treated with four anti-

tuberculosis drugs (isoniazid, rifampicin,

pyrazinamide, and ethambutol), oral corticosteroid,

mannitol infusion, and normal saline infusion.

Antibiotic meropenem was added to the treatment.

Previously before admitted to HCU, the patient had

been given ceftazidime as an antibiotic. The patient

showed improvement after 3 days in the HCU. His

consciousness began to improve, no headache and

nuchal rigidity and maintained a stable of

hemodynamics. The patient still had right

hemiparesis. He was moved to the ward and was

discharged with the anti-tuberculosis regimen and

oral corticosteroid.

Figure 3: Head CT scan shows mild hydrocephalus in the

fourth and temporal ventricle.

The patient was then scheduled for having

physiotherapist regularly twice a week. With regular

administration of the anti-tuberculosis drug, oral

corticosteroid, and physiotherapist, the patient

showed an improvement in his motoric function.

Two weeks after being discharged from the hospital,

he was able to walk by himself.

3 DISCUSSION

Neuro-tuberculosis is the most serious complication

of TB in children. Among the various forms of

neuro-tuberculosis, TBM remains the most severe

and the most common in developing countries

(Torok, 2015). Tuberculous meningitis continues to

be an important cause of morbidity (especially

neurologic impairment) in children from resource-

poor countries (Israni, et al., 2016).

Owing to the suboptimal performance of

diagnostic tests of TBM, the diagnosis in children

relies on a thorough assessment of all the evidence

derived from a careful evaluation of medical history,

clinical examination, and relevant investigations.

Approximately 60% of children with TBM have

radiological evidence of pulmonary TB (Toorn &

Solomons, 2014).

Tuberculous meningitis is a subacute meningitis

illness, which presents in various stages. According

to the British Medical Council Staging System,

tuberculous meningitis can be divided into 3 stages.

The first stage consists of nonspecific symptoms of

low-grade fever, headache, irritability, drowsiness,

malaise, vomiting, photophobia, listlessness, and

poor weight gain/weight loss. The second stage

shows a sign of meningeal irritation with or without

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slight clouding of consciousness with focal

neurological signs such as cranial nerve palsies or

hemiparesis. In advanced clinical stages, TBM

presents severe clouding of consciousness or

delirium, convulsions, and serious neurological signs

such as hemiplegia, paraplegia, involuntary

movement (Israni, et al., 2016).

Tuberculin skin test (Mantoux test) may be

nonreactive in 50% cases of CNS TB. Hence, it is

helpful in supporting the diagnosis of TBM when

positive, but an isolated positive Mantoux cannot be

used to label a case of TBM, as false positive/false

negative reactions are commonly known (Aulakh &

Chopra, 2018).

Tuberculous meningitis usually presents with a

Cerebrospinal fluid (CSF) of 10–500 cells/μL that are

polymorphs initially and lymphocytes later. A low

glucose <40 mg/dL (rarely<20 mg/dL) or a

CSF/plasma glucose ratio <50% or a high-protein

content (400–5000 mg/dL) is suggestive of the

diagnosis of TBM. The CSF lactate levels are usually

raised to 5–10 mmol/L (normal range, 1.2–2.1

mmol/L). Ziehl–Neelsen (ZN) staining for the smear

examination has a sensitivity of approximately 50%,

whereas a bacterial culture has a sensitivity of 60% to

70% (Aulakh & Chopra, 2018). CT scanning and

MRI of the brain may reveal hydrocephalus, basilar

meningeal enhancement, infarcts, edema, and

tuberculomas (Toorn & Solomons, 2014).

This patient presented with a decreased level of

consciousness, headache, nuchal rigidity, positive

Babinski sign, right hemiparesis. TB IGRA was

positive in this patient. He previously complained of

cough and fever for two weeks and weight loss for 1

month.

Chest X-ray also showed miliary tuberculosis,

and the CT of the Brain showed mild hydrocephalus

which suggests meningitis. From the clinical

examination, diagnostic tests, this patient can be

categorized into stage 2 of TBM.

WHO recommends a 12-month treatment plan

(2RHZE/10RH) for children with suspected or

confirmed TBM (Toorn & Solomons, 2014). We

gave anti-tuberculosis drugs to this patient according

to the WHO guideline. Meropenem was given due to

the possibility of bacterial meningitis that is evidently

suggested by leukocytosis and increased neutrophil

count. Hyponatremia occurs in up to 85% of children

with TBM and is thought to be secondary to either

syndrome of inappropriate antidiuretic hormone or

cerebral salt wasting. We also found hyponatremia in

this patient which was treated with normal saline

fluid. Corticosteroid oral was given to reduce the risk

of death and neurological deficit (Toorn &

Solomons, 2014).

The patient showed clinical improvement in his

motoric function after being given an anti-

tuberculosis drug regimen, oral corticosteroid, and

physiotherapist.

4 CONCLUSION

Patients with TBM develop typical symptoms and

signs of meningitis including headache, fever, and

stiff neck, although meningeal signs may be absent

in the early stage. The duration of symptoms before

presentation ranges from several days to several

months. In particular, in resource-limited settings,

TBM cases may present in advanced clinical stages,

with GCS scores of 10 or less. Cranial nerve palsies,

hemiparesis, paraparesis, and seizures are common

and should raise the possibility of tuberculous

meningitis as the etiology of meningitis (Chin,

2014).

This case shows that clinical symptoms of

tuberculous meningitis can appear as hemiparesis

without a seizure. Proper treatment of tuberculous

meningitis may lead to a better outcome.

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