An 18-year-old immune-competent male patient with no significant medical history was admitted to our hospital with 1-week history of headache, fever, and change in mental status suggestive of meningitis. The CSF analysis showed a high leucocyte count, lymphocyte predominance (92%), and high protein (0.92 g/L) and relative low glucose levels (4 mmol/L). Rapid TB PCR, HSV PCR, and India ink staining test results were negative. Chest imaging and sputum analysis did not reveal any positive findings. Initially, he was treated empirically for pyogenic meningoencephalitis. Follow-up computer tomography (CT) and MRI performed 2 weeks later showed hydrocephalus and basal meningeal disease with a pattern of cystic nodular enhancement (Figures 1 and 2) highly suggestive of TBM. At this time, the patient was also empirically treated with anti-TB medications (rifampicin, isoniazid, ethambutol, and pyrazinamide) supplemented with steroids. An external ventricular drain was placed, followed by conversion into a VPS. MRI of the spine revealed diffuse smooth dural thickening, representing nonspecific meningitis. The patient showed slow improvement and was discharged only on anti-TB medications.
After approximately 3 months, the patient was readmitted with bilateral leg weakness. The MRI of the spine showed progressive diffuse dural thickening and enhancement with intradural thick-walled abscesses causing cord compression and edema (Figure 3). The patient underwent spinal decompression. Acid-fast bacilli (AFB) stains were negative and mycobacterial culture did not show growth. However, the patient was continued on first-line anti-TB therapy.
Approximately 6 months later, he presented with shunt dysfunction and an enlarging abdominal cystic mass related to the tip of the VPS catheter revealed by CT of the abdomen (Figure 4). Laparoscopy showed a large pseudocyst with local inflammatory changes. The pseudocyst was drained and resected and the VPS was removed. Finally, mycobacterium complex was isolated in culture from the cyst aspirates and a CSF shunt tap (mycobacterium complex included M. tuberculosis, M. africanum, M. bovis, M. microti, and M. pinnipedii). Multidrug-resistant TB was confirmed by a drug sensitivity test, given resistance to rifampicin and isoniazid and sensitivity to ethambutol and pyrazinamide. This led to modifying the regimen to a 7-drug therapy including moxifloxacin, pyrazinamide, ethambutol, ethionamide, and cycloserine (for at least 12 months), in addition to Amikacin and Linezolid (for 6 months). An external ventricular drain was inserted and then removed after passing the clamp-challenge test. Patient showed slow progressive clinical improvement with no new disease and stable appearance, specifically with respect to the nodular basal meningitis and ventricular caliber.