TB MENINGITIS AND PULMONARY TUBERCULOSIS MILIARY FORM IN A PATIENT ON A IMUNOSUPPRESIVE TREATMENT

Author: Claudiu Teodorescu

Co-authors: Anca Marian, Marinela Tatu, Rebecca Şerban, Florina Zdîrcea

Scientific coordinators: Teach. Assist. Irina Niculescu MD, PhD

Tuberculosis is a major public health problem, worldwide is the second cause of death by the infectious disease, after infection with HIV. TB meningitis, caused by the haematological spread of Mycobacterium tuberculosis, is one of the worst forms of extrapulmonary tuberculosis whose evolution, untreated, is invariably fatal.

We present the patient SV, F gender, 52 years old, from urban environment, hospitalized in 2nd Clinics of Adults Infectious Diseases, Hospital "Victor Babeş" Craiova for headaches, vomiting, generalized weakness. The onset of this disease was insidiously, with 3 weeks before hospitalizing with chills, cough, intense headache; from 1 week appears vomiting and generalized weakness. From the past medical history we retain vulgaris psoriasis in biological treatment with Infliximabum for 2 years ago. Clinical examination: general state altered, no fever, pallid face. We see erythemato-squamous elements localized on skin and on the large joints of both of members. Normal pulmonary and cardiac stethacoustic parameters. Heart rate= 60bpm, blood pressure= 100/60mmHg. Abdomen was soft, nondistended, with normal active bowel sounds. No signs of meningeal irritation. Biological: complete blood count is normal, VSH- 18/38 mm, easy hepatocytolysis (ALAT=74 U/l). CXR – micro point opacities disseminated in both lung fields. Lumbar Puncture: CSF with clear aspect, WBC count: 225 cells/mm3, 100% mononuclear cells, Pandy reaction ++, protein level= 66mg%, Cl-= 760mg%, glucose level= 15,1mg%. First stage diagnostic: TB meningitis, pulmonary tuberculosis miliary form, vulgaris psoriasis in biological treatment. Later in the cultures of CSF developed M. tuberculosis. It was established the treatment with ATT, glucocorticoids, mannitol and symptomatics, with favorable development.

This case is particular due to the atipical aspects- both clinical ( lack of fever, absence of meningeal irritation) and biological ( no biological inflammatory syndrome, a slightly modified CSF biochemistry) of the tb meningitis in a patient on immunosupresive treatment.