CHSU Discovery

Abstract:

Introduction:This case report aims to present a challenging diagnostic journey encountered in a 79-year-old Tagalog-speaking female with tuberculosis meningitis. This study aims to shed light on the difficulties faced during the diagnostic process. Due to the nature of her initial symptoms, a high index of suspicion for meningitis was maintained throughout the diagnostic process.

Case Description: The patient arrived exhibiting signs of an altered mental state and fever, which suggested a potential case of meningitis. On arrival, the patient had a blood pressure of 99/58 and was tachycardic with a heart rate of 115, a respiratory rate of 24, and a fever of 102.8 F. The patient was saturating 97% on room air. Labs were significant for potassium of 3.1, bicarbonate of 18, lactic acid 4.5, and a Pro-Cal of 1.38. Chest x-ray showed moderate vascular congestion. CT of the abdomen pelvis showed significant thickening of the rectal wall. A sepsis alert was initiated, and the patient was given 30 cc/kg of fluids and started on IV Zosyn in the emergency department. The patient was admitted to telemetry for severe sepsis, and at that time, it was secondary to an unknown etiology. Blood cultures and urine cultures were taken, and urinalysis was negative. 

Discussion: Considering the patient's age and wide range of possible diagnoses, a comprehensive exam, labs, lumbar picture with CSF analysis, and imaging were conducted. The Cerebrospinal Fluid (CSF) analysis unveiled a high protein level, lymphocytic pleocytosis, and reduced glucose levels. These factors align with Tuberculosis (TB) meningitis symptoms, a conclusion further supported by the patient's positive TB Quantiferon result. All other CSF studies, including HSV, cocci, and West Nile, were negative. The patient had no respiratory symptoms to suggest pulmonary TB, and her chest X-ray was negative for TB. The patient was started on RIPE therapy, steroids, and B6. After beginning treatment, the patient's symptoms began to improve.

Conclusion: Diagnosing tuberculosis meningitis can be particularly challenging, especially in elderly patients with nonspecific clinical manifestations and a wide range of differentials to consider. This case report highlights the importance of maintaining a high index of suspicion in the face of diagnostic uncertainty. It emphasizes the significance of thorough evaluation, including examination, CSF analysis, and molecular testing, in confirming the diagnosis. Timely identification of tuberculosis meningitis is crucial for initiating appropriate treatment promptly, thus improving patient outcomes.