A 37-year-old female with retroviral disease was brought to casualty by caregivers because she was confused. The confusion was preceded by severe headache for 3 weeks. She had no history of vomiting or neck stiffness. She had started antiretroviral drugs 2 months earlier and subsequently defaulted.
On initial clinical examination, the patient was confused (not orientated to time, place, or person), pyrexial, and pale. She was normotensive (108/80 mmHg) but had a tachycardia of 107 beats per minute. The cardiac examination was otherwise normal. She was tachypneic with a respiratory rate of 22 breaths per minute and crackles throughout both lung fields. Neurologic examination identified neck stiffness without localizing signs.
Blood tests, microbiology, lumbar puncture analysis, and a chest film were done (Tables 1-6 and Figure 1). The patient had normocytic normochromic anemia, hyponatremia, and a slightly raised alanine transaminase. Her viral load was raised (678,233 copies/mL) and her CD4 count was low (155.28 x 106/L). Cerebrospinal fluid analysis showed an increase in lymphocytes, a raised protein level, and decreased glucose (Table 4). India ink staining and a Cryptococcus latex antigen test were both negative (Table 4). Sputum analysis and blood cultures were negative for Mycobacteria (Table 7).
The anterior-posterior supine chest film with the patient rotated to the right (Figure 1) showed bilateral nodular infiltrates with hilar and mediastinal lymphadenopathy not excluded. A veiling pleural effusion was noted on the left, and the left cardiac border was obscured by confluent opacification in the lingular segment of the left upper lobe.
The patient was initially assessed as having disseminated tuberculosis with central nervous system involvement, specifically meningitis. She was admitted to the medical ward and started on antituberculosis therapy, glucocorticosteroids, and supportive care.
On day 2, the patient developed both inspiratory and expiratory stridor and her initial respiratory distress worsened, with the respiratory rate increasing to 46 breaths per minute. The patient was started on adrenalin nebulization. The patient was intubated in theater and then transferred to the high care ward with a T-piece attached to the endotracheal tube. The glottis appeared normal during endotracheal intubation. At this point she was normotensive (113/73 mmHg), tachycardiac (152 beats per minute), and tachypneic (54 breaths per minute). Her oxygen saturation was 94% on 40% oxygen via a T-piece. A computed tomography (CT) scan of her brain and chest were requested. Unfortunately, the CT scanner at the base hospital was not working and the patient was deemed too unstable for transport to a CT scanner 2 hours away. High-dose cotrimoxazole, piperacillin/tazobactam, and amikacin were initiated. The patient remained pyrexial with a temperature of 38 C.
On day 4, the patient's oxygen saturation dropped to 92% and her arterial oxygen was 59 mmHg on 40% oxygen. Her chest film suggested a left-sided pleural effusion. Her blood pressure was also decreasing and central venous pressure was low (0 cm H2O). The central venous pressure was optimized and inotropic cardiac support was initiated. The patient's level of consciousness improved.
On day 7, she developed worsening hepatic impairment so her treatment was changed to a "liver-friendly" tuberculosis regimen. Clinical improvement was noted (improved level of consciousness, pulse 104 per minute, blood pressure 94/68 mmHg, oxygen saturation 100% on 60% T-piece oxygen, central venous pressure 8 cm H2O, respiratory rate 36 breaths per minute) and it was decided to taper her inotropic support.
On day 12, the patient extubated herself. Her vitals at this point were as follows: pulse 102 per minute, oxygen saturation 98% on 40% face mask oxygen, respiratory rate 30 breaths minute, and blood pressure 147/71 mmHg. Vesicular lesions with a dermatomal distribution were noted on her buttock and the patient developed diarrhea. The endotracheal tube and stool were sent for microbiologic analysis (Table 7). Approximately 9 hours later, the patient desaturated and was reintubated. The patient then underwent a tracheostomy.
The following day she suffered a cerebrovascular accident with left hemiplegia. The patient died later that day, approximately 2 weeks after admission.