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A Case of TB meningitis with Pituitary TB

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  • 1. An interesting case of Tuberculosis
    DevendraPatil
    Dr. Prof. Magheshkumar Unit
    M1 unit
  • 2. We sincerely thank
    Dr. Chenthil ( IMCU chief )
    Dr. Gowrishankar and M3 team
    Dept of Neuro-Surgery
    Department of chest medicine
    Endocrinology dept, SMF
    Apollo Hospital Labs
  • 3. Case history
    A 21 year old unmarried girl came to GSH with chief complains of
    Fever ( low grade, evening rise)…………..10 days
    Altered behavior………..4 days
    Increased drowsiness…….3 days
  • 4. No h/o
    convulsions
    Neck pains , headache , vomiting
    Fall/trauma to head
    Weakness in any on the limbs , diplopia
    Cough with expectoration
    Abdominal pains
    Join pains / swelling
    Body rash
    Swellings in neck , axilla , groin
    Jaundice in past
    TB in past / family
  • 5. o/e
    She is drowsy , responding to painful stimuli ,
    GCS – 10/15
    Temp 100 F
    P- 94 /min regular
    RR – 16 / min regular
    BP – 130/80 mm Hg
    No pallor / ict / cyn /club / LN / pedal oedema
    Neck veins – normal
    Skin -normal
    No external markers of TB
    CVS : NAD
    RS : NAD
    PA : NAD
  • 6. CNS
    Higher mental function
    Drowsy
    Disoriented
    Responding to painful stimuli
    Cranial :
    Pupils – B/L equal reacting to light
    Fundus : b/l normal, no e/o papillodema
    no other cranial nerve involvement
    Spinomotor: tone is normal in all 4 limbs
    power is 3+/5 in all limbs
    all DTR are present and normal
    B/L plantar - flexor
    Sensory : response to pain present,
    Cerebellar : no signs present
    Meningeal : neck rigidity +nt
    Kernigs –ve , Brudzinki –ve
    Skull and spine - normal
  • 7. Problems
    Subacute fever
    Altered behaviour
    Neck rigidity
  • 8. Working Diagnosis :
    CNS infection
    - TB
    - cerebral malaria
    - bacterial meningitis
    - aseptic meningo – enephalitis
    Plan:
    Baseline investigations
    IMCU care
    Empirical treatment for CNS infection
    CSF analysis
    Neuro-imaging
    Steroid dose
  • 9. Investigation
    Hb – 9.8 gm%
    TC – 5600/cc
    DC – P56,L32
    ESR – 22mm/hr
    Platelet – 2.3 lac
    RBS – 84 mg%
    Urea – 21 mg%
    Cr – 0.7 mg%
    Na – 139 meq/L
    K – 3.7 meq/L
    CSF analysis :
    Physical : clear
    Pressure : high ( not measured )
    Protein : 140 mg%
    Sugar - 34 mg %
    Cells - 8-10 lymphocytes seen
    ADA - 7 IU/L
    Cytology – lymphocytes seen
    Grams Stain - negative
    AFB stain – negative
    PCR ( MTB )– not sent
    IMPRESSION :
    Suggetsive of TB meningitis
  • 10. NEUROIMAGING
    What to expect in a case of TB meningitis ?
    Infarcts ( due to vascuitis )
    Granuloma
    Arachnoiditis
    Subpial / subependymal foci of TB
    Ependimitis
    Leptomenigealenchancement
    Exudation
    Choriodplexitis
    Hydrocephaleus
  • 11.
  • 12.
  • 13.
  • 14.
  • 15.
  • 16.
  • 17.
  • 18.
  • 19. Neuro imaging
    CT Brain : Normal study
    MRI BRAIN :
    Right thalamus infarct
    Pontine , occipital , parietal SOL
    Ring enhancement present
    Lepto-meningeal enhancement
    Occiptal exudates
    f/s/o--- CNS tuberculosis
  • 20. ATT registration and commencment
    Antibiotic policy changed
    Steroids continued
    Patient general condition improved
    Shifted to ward and accordingly discharged
    She was asked to continue ATT at nearby DOTS centre
  • 21. 5 months later………….
    She came with chief complains of
    Secondary Amenorrhea …….. 5 months
    Excessive Weight gain ……….. 5 months
    Altered behaivour …………..2 weeks
    Drowsiness , Headache , Vomiting ……………
    Excessive sleepiness…………………. 2 weeks
  • 22. O/e
    She is drowsy , responding to oral stimuli ,
    T- afebrile
    P – 86 /min
    RR- 14 / min
    BP – 100/70 mm Hg
    No pallor / icterus / cyn /club /nodes
    Facial puffiness seen
    Decreased frequency of urination
    No pedal edema
    CVS - NAD
    RS - NAD
    PA - NAD
  • 23. CNS :
    Higher mental function:
    Drowsy
    Not oriented
    Responding to painful stimuli
    CRANIAL NERVES:
    Pupils – B/L equal reacting to light.
    no ophtalmoplegia
    no papillodema
    No other cranial nerve involvement
    SPINOMOTOR : tone and reflexes were normal
    SENSORY : pain sensation preserved
    Meningeal : neck stiffness present
    Kernig sign - absent
    Cerebellar : couldn’t be assessed
    Spine , Skull - normal
  • 24. Problems
    c/o TB meningitis on ATT since 5 months
    Non – compliance
    Incomplete steroid treatment
    Meningeal signs
    Secondary Amenorrhea
    Altered behaivour
    Weight gain with reduced urine frequency
  • 25. Possibility
    TB relapse
    TB Hydrocephalus
    Hyponatremia
    Chronic meningitis of different etiology
  • 26. Investigation
    Hb – 10 gm %
    TC – 6500 /cc
    DC – P60,L35
    ESR – 25 mm/hr
    Platelet – 1.2 lac
    RBS - 90 mg%
    Urea – 27 mg%
    Cr- 0.6 mg%
    Na - 124 meq/L
    K – 3.6 meq/L
    CSF analysis :
    Physical - clear
    Pressure – high ( not measured )
    Protein - 120 mg %
    Sugar - 29 mg%
    Cells - few lymphocytes
    ADA – not sent
    Cytology - acellular
    Grams Stain - negative
    AFB stain – negative
    Impression :
    Suggestive of TB meningitis
    Or incompletely treated pyogenic meningitis
  • 27. On the 3rd day of re-admission patient developed precipitous neurological detoriation and complained on binocular diplopia
    Causes:
    Cerebral edema
    Hyponatremia
    Raised ICT
    hydrocephalus
    She was given iv. mannitol and iv. steroids
    An emergency CT brain was requested and promptly done.
  • 28.
  • 29.
  • 30. An emergency call - over to neuro surgery dept was given and they took over the patient for an immediate ventricular decompression surgery.
    Post surgery patient recovered
    Became more responsive and there was a dramatic reduction in the facial and pedal odema.
    Patient was shifted back to medicine wards 10 days later.
  • 31.
  • 32.
  • 33. Siadh
    There is a strong suspicion that part of the delirium in our patient could be due to SIADH secondary to CNS tuberculosis and the ensuing communicating hydrocephalus
    The points that are in favour are
    Hypo-osmolarHyponatremia
    Reduced urinary frequency
    Urine 24 hr Na+ levels 916 meq/L
    Altered behaivour
    Clear-cut etiology
    brisk diuresis following relief of hydrocephalus
    pt lost weight and became as she was about 5 months back
    However the points not in favour are :
    Presence of f/s/o overhydrated state
    Urine osmolality studies not done
  • 34. Problems that were still persisting
    Patient still drowsy
    Prefered to sleep most of the day
    Reduced appetite
    Secondary Amenorrhea
    Lower range of BP
    Generalised apathy to surroundings
  • 35. Possibilities
    VP shunt malfunction / blockade
    Hyerprolactinemia
    TB of genitourinary tract ( hypogonadism )
    Plan :
    Neurosurgical review
    Gynacological opinion
    Neurological opinion
    Repeat electrolytes
  • 36. Neuro – surgical opinion: nil active currently
    shunt working
    Gynecological opinion:
    Urine pregnancy test negative
    USG Abdomen and pelvis – normal study
    T. Megestrol –for withdrawl bleeding
  • 37. Thyroid profile
    In v/o increased weight and listless behaivour
    Free T3 - 2.3 (2.4 – 4.2 pg/dl)
    Free T4 - 0.6 ( 0.8 – 1.7 ng/dl)
    TSH – 0.2 ( 0.4 – 4.0 IU/l)
    Impression : hypothyroidism secondary
  • 38.
  • 39.
  • 40.
  • 41. Prolactin fasting : 40 ug/L ( 0-20)
    S. cortisol 8a.m. fasting – 6.9 ug/L ( 8-25)
    S. LH -- 0.1 uIU/L ( 2-15)
    S. FSH --0.2UuIU/L ( 3-26)
    Impresssion:
    Mildly elevated prolactin
    Hypogonadotropichypogonadism
    Hypocortisolism
    Secondary hypothyroidism
  • 42. Possibilites:
    TB of the pituitary gland
    TB exudation causing Hypothal pituitary axis supression ( stalk – section effect )
    Further plan:
    MRI imaging of the pituitary gland
  • 43. neuroimaging
  • 44.
  • 45.
  • 46.
  • 47.
  • 48.
  • 49.
  • 50. Treatment given:
    ATT under cat 1 to be continued
    Repeated counselling regarding the compliance
    T. Eltroxin 50 ug/day
    T. Hydrocort 20mg/8am and 10 mg/8pm
    T. Estrogen
    T. Progesterone
    Her condition improved to an extent that she was able to do her work independently.
  • 51. Final Diagnosis
    TB chronic meningitis
    Sequaelae
    Communicating hydrocephaleus
    VP shunt in situ and functioning
    anterior - Hypopitutarism
    Pituitary tuberculosis
    On hormone replacement therapy
  • 52. What is so different in this case
    The propensity of TB to affect the pituitary is rare.
  • 53. What is so different in this case
    The lesion is primarily in the pitiutary or the hypothalamus is quite uncertain.
  • 54. Why a ACTH stimulation and GHRH stimulation test not done
  • 55. Why was a PCR not done
  • 56. Most of the case reports have a histopathological diagnosis.
    Hence a trans spenoidoidal biopsy should be done as an ultimate proof of the pathology
  • 57. What is so different in this case
    The development of clinically apparent TB hypopituitarism when the patient is already on ATT is puzzling.
  • 58. KEY MESSAGE….
    TB pituitary is rare but known entity
    Recent onset of altered behaivour , apathy , secondary amenorrhea especially in endemic regions should suggest possibility of tuberculous involvement of hypophysiscerebri.
    It is important for us to keep a high index of suspicion in managing cases of CNS tuberculosis to pick up its complications very early in the course
  • 59. Thank you
    References :
    Harrison’s 16/e
    Sharma – tuberculosis
    K Sunil, et.al.,Pituitary Tuberculosis. JAPI 2007.