Abstract Ref Number = APCP1129
CHALLENGES IN DIAGNOSING AND MANAGING DRUG-RESISTANT TUBERCULOUS MENINGITIS
Pandu Caesaria Lestari, Citra Raditha, Anna Tjandrajani, Dimas DwiSaputro,
Pediatric Neurology and Respirology Working Group
Harapan Kita Women and Children Hospital
Background: Tuberculous meningitis (TBM) is associated with significant complication of central nervous system. Tuberculous meningitis from MDR strain is associated with high mortality and now an emerging health problem. An estimated 490,000 people worldwide develop multi drug-resistant tuberculosis (MDR-TB).
Case Presentation Summary: A 16-year-old female with miliary TB who had been treated for 4 months came with severe headache, altered mental status, and hemiparesis. Physical examination and diagnostic tests consistent with TBM with hydrocephalus. First-line intensive antituberculous therapy and prednisone were given, and ventriculoperitoneal shunt was inserted.
Her level of consciousness improved, but the hemiparesis progressed to quadriparesis. Brain MRI found tuberculoma in her left pons, and MR Spectroscopy showed grossly diminished N-acetylaspartate and distinct lipid peak, but normal level of choline and creatine. Nucleic acid amplification test from cerebrospinal fluid found negative result. HIV and immunodeficiency test were negative. Antituberculous therapy and prednisone was continued with adjusted dose. Patient’s condition improved and was discharged.
Patient was re-admitted 2 weeks later with deteriorated consciousness and neurologic condition, and more severe pulmonary TB. Brain CT showed hydrocephalus due to distal obstruction from progression of tuberculoma. Second nucleic acid amplification assay from the cerebrospinal fluid was done, and found Rifampicin-resistance Mycobacterium tuberculosis. She was then started on second-line antituberculosis agents consisting of pyrazinamide, ethambutol, levofloxacin, cycloserin, ethionamide, and kanamycin. She had also suffered pneumothorax, sepsis, and severe pressure ulcer throughout hospitalization but then finally discharged in good condition.
Learning Points: Resistance to first-line antituberculosis agents should be suspected in patients who show minimal improvement, because delay in starting second-line drug will significantly increase morbidity and mortality. This patient has MDR-TBM, even tough she has showed improvement but close follow up still need to be done.
Keywords: tuberculous meningitis multi-drug resistant nucleic acid amplification test