A 49-year-old married Indian man presented to the Emergency Department of Hamad General Hospital in Qatar, with fever, headache, lower limb weakness, and urinary incontinence for 1 month. His complaints were also associated with fluctuating episodes of confusion and agitation for 4 days. He had not experienced vomiting, convulsions, loss of consciousness, diplopia, facial weakness, or dysphagia. He had no history of trauma; fall; cardiac, respiratory, genitourinary, gastrointestinal, or musculoskeletal abnormality; or drug intake or intoxication. Review of his past medical documents revealed visits for evaluation of cervical lymphadenitis with inconclusive results. On assessment of his living conditions and housing, the patient stated that he lives in a crowded house with multiple roommates, of which one had prolonged cough without professional diagnosis.
On examination, the patient looked pale, had stable vital signs, agitated, confused, had neglected appearance with poor hygiene and having an odour smelling like urine. On neurological examination, he was conscious, alert, but not oriented, with a Glasgow coma scale of 12/15. Signs of meningeal irritation were negative. His motor examination showed decreased strength in both lower limbs (4/5) as well as diminished reflexes. His cranial nerves, sensory, and cerebellar examination were equivocal. Other systemic findings were normal.
His 1-month history of headache, fluctuating hallucinations, and confusion led us to consider the possibility of CNS infection. All basic laboratory tests were performed, including complete blood count, urea and electrolytes, blood culture and sensitivity, and C-reactive protein (CRP). Lumbar puncture was performed under conscious sedation. Initial investigations showed a minimal increase in leucocyte count and CRP, but he had normal renal and liver functions. Chest X-ray imaging did not show any abnormality, and computed tomography finding of the head was normal. High lymphocytes, high protein, and low glucose were detected in the cerebrospinal fluid (CSF).
The patient was admitted under the care of the medical team and was empirically started on anti-TB medications and antibiotics. MRI, acid-fast bacilli, and QuantiFERON gamma assay were performed. MRI of the head and spine (Figures 1-3) showed extensive basal intracranial meningeal thickening and enhancement extending along the spinal canal circumscribing the whole spinal cord down to the conus medullaris region (Figures 2, 3). Intramedullary high signal intensity was observed along the cervical spinal cord from C3 down to the C7 vertebral level and the lower thoracic spinal cord opposite the tbl10-11 and tbl12 vertebral level, yet no abnormal post-contrast enhancement was detected (2). This picture was highly suggestive of extensive craniospinal TB meningitis.
The patient showed dramatic improvements in his orientation and conscious level after 7 days of receiving anti-TB management and was discharged from the acute medical ward to the rehabilitation center to address his lower limb weakness.