A 22-year-old Asian woman developed marked changes in behavior and personality following the delivery of her first baby (Figure 1). She gave birth in the 33rd-34th week of gestation due to premature rupture of the membrane (PROM). The baby weighted 2,000 g with body length of 43 cm and APGAR score of 6 and 8 for 1 and 5 min, respectively.
The patient ignored the doctor's and family's questions after the delivery. She was known to be irritable due to the emergency cesarean section. She felt sleepy; however, she could not fall asleep. Her breastmilk production was very low which made her even more irritated. She also looked confused and kept babblings meaninglessly to herself. She admitted that she heard the ghost's voices which could not be heard by others.
Three months before admission, her sister posted her pregnant belly on social media without her permission, which induced conflict between the two. She shut herself for 2 months in her room and refused to eat, therefore she lost some weight. Three weeks before admission, the patient sometimes was seen crying without any specific reasons. She felt sad, fatigued, and lethargic. She also had a conflict with her husband because he ignored her request on getting health insurance. Set aside, she also got mad at her mother for no apparent reason. In addition, she experienced frequent intermittent headaches associated with mild fever which had been felt for 3 weeks before admission. The patient had been brought to the nearest health care facility for several times to check her complaint of headache. The doctor found that she experienced anemia and low blood pressure which is common in a pregnant woman. The patient then was prescribed analgesics and vitamins. There was no history of mental illness in the patient and her family. There was no known head trauma. Patient's family believe those symptoms related to her pregnancy.
At the time of admission, after having a cesarean section due to PROM, she had fever (temperature: 38.7 C) with other physical examinations showed no abnormal findings. Patient was treated with cefazolin, ketoprofen, pethidine, and ketorolac regarding to her condition. Two days after admission, patient experienced loss of consciousness which was suspected due to electrolyte imbalance by physician in Emergency Department at the time of admission. Thus, she was followed up by internist. However, there was no abnormality in either electrolyte or metabolic process.
Biochemical investigations were done several times since the patient's admission. After patient lost her consciousness, 2 days after admission, the hemoglobin level was 8.2 g/dl (reference range: 12.3-15.3 g/dl), platelet count was 308 x 109/L (reference range: 150-400 x 109/L), and white blood cells count was 11 x 109/L (reference range: 4-11 x 109/L). Other laboratory results including calcium, glucose, blood urea nitrogen, and creatinine were normal.
She then turned into hypoactive with a negative attitude. The rapport was inadequate. She remained silent while being asked by physicians. Due to her behavioral changes, she was consulted to Psychiatric Department. According to her complaint, she was diagnosed with depressive disorder with peripartum onset. Depressive disorder was diagnosed because the patient had depressed mood most of the day; diminished interest or pleasure in all, or almost all, activities most of the day; significant weight loss; fatigue or loss of energy; feelings of worthlessness in the last 3 months. The patient was treated with olanzapine 5 mg per day. The next day, the patient screamed uncontrollably and became hysteric. Due to her condition, lorazepam 0.5 mg per day was added into her therapy regimen. Later, she developed auditory hallucination of hearing ghost's voices which no one else can hear.
Five days after admission, she was then consulted to a neurologist for further assessment of her headache. From the assessment of the neurologist, the Glasgow Coma Scale (GCS) was 14 with a positive meningeal sign. Cranial nerve (CN) examinations revealed paresthesia on the right side of her face. Motoric examination revealed tetra paresthesia with positive pathological reflexes. She was suspected with tuberculous meningitis grade I and suggested to undergo thorax X-ray examination, computed tomography (CT) scan with and without contrast, and lumbar puncture.
The following day, a non-enhanced CT scan of her head revealed hypodense lesions at right subcortical occipital lobe, left parietooccipital lobe, and right cerebellum accompanied by hydrocephalus. Those lesions could be an infarct due to embolization with differential diagnosis of posterior reversible encephalopathy syndrome (PRES) and tuberculoma. In an enhanced CT, we found an overlie meningeal enhancement at sulci cortical right occipital lobe, bilateral sulcus cortical temporal lobes, tentorium cerebelli, ambient cisternae, basalis cisternae, bilateral Sylvia fissures, anterior and posterior interhemispheric fissure with hydrocephalus communicans, which suggested an additional diagnosis of meningitis (Figure 2). She also underwent several other imaging to support the diagnosis of possible underlying disease. An abdominal ultrasound scan revealed hepatosplenomegaly and multiple paraaortic lymphadenopathies, which added additional suspected diagnosis of tuberculous peritonitis. A chest X-ray was performed and suggested active pulmonary tuberculosis and cardiomegaly with lung oedema.
Based on the latest result that day, psychiatric diagnosis was revised to peripartum depression and neurocognitive disorders due to brain dysfunction due to tuberculous meningitis and patient was treated with clozapine 5 mg and lorazepam 0.5 mg. Also, neurologist updated the diagnosis into to tuberculous meningitis grade II with arteritis and suspected arachnoiditis, intracranial space occupying lesion due to tuberculoma. Patient was soon treated with rifampicin, isoniazid, pyrazinamide, ethambutol, dexamethasone, vit B6, omeprazole, and paracetamol.
Seven days post cesarean section, the patient suddenly complained of pain throughout her body. She developed shortness of breath with a respiratory rate up to 28 x/m, fever (temperature: 38.9 C), low blood pressure 90/70 mmHg, and decreased oxygen saturation (SpO2 80%). The patient then stopped breathing. Twenty minutes after being resuscitated, the patient did not show any response and was declared dead with suspected pulmonary embolism as cause of death. However, confirmation was not possible because a thorough postmortem study was not performed.
Lumbar puncture was scheduled to be done on the patient after an enhanced CT scan result was obtained. However, patient died before the test was held. We also did the acid-fast bacilli (AFB) test; however, the patient passed away before the result came out.