A 33-year-old male who had been experiencing neck pain for a month and dysuria for a week was admitted to a local hospital for examination. Cervical MRI plain scan and enhanced scan done at the local hospital revealed multiple abnormal signals in the central canal of spinal cord on November 28, 2021 (Figure 1). Primary lumbar puncture (LP) was performed, and his CSF suggested high protein (2.95 g/L, normal range 0.15-0.45 g/L), high white blood cells (WBC) count (243*106/L, normal range 0-8*106/L), low glucose level (0.88 mmol/L, normal range 2.3-4.1mmol/L) and low chloride level (113 mmol/L, normal range 119-129 mmol/L). Color Doppler sonography of urinary system suggested right renal cyst, turbid urine in the bladder, prostate calcifications and prostate cyst. Ceftazidime was given anti-inflammatory treatment during local hospitalization, but he did not show improvement and had trouble defecating after 2 days. On the third day the patient was transferred to our hospital for further treatment.
The patient had dizziness, headache, nausea and vomiting occasionally, however, no physical activity disorder and no fever was present during the early stage. The patient was previously healthy and had occasional neck pain a year ago, which resolved spontaneously. Neurological exam showed right lower limb muscle strength grade 4, Kernig sign (+), neck rigidity (+), and a bilateral Babinski sign, all other neurological examination were otherwise normal. The brain MRI were conducted on the second day following admission, shows abnormal signal and nodular enhancement of medulla oblongata and cervical medulla. Considering the patient's long spinal cord lesion, mannitol Q6H dehydration treatment was given at once. Upon admission, based on the clinical symptoms, the possibility of myelitis was considered. Levels of AQP4, MOG, MBP and GFAP antibodies in serum and CSF were measured and negative.
We performed LP to collect CSF on the third day following admission and yielded a surprising result. CSF routine test showed high intracranial pressure (240 mmH2O, normal range: 80-180 mmH2O). CSF was yellow and cloudy (Figure 2B), the Pandy test was strongly positive (++++), the protein was 46 g/L (normal range 0.15-0.45 g/L), which was an unbelievable result. His CSF glucose was also extremely low (0.28 mmol/L, normal range 2.3-4.1 mmol/L), which was a significant deterioration compared to the last test performed a week ago. Cytology was not possible due to rapid coagulation of the patient's cerebrospinal fluid.
The patient's condition deteriorated rapidly. Combined with the imaging findings and extremely elevated cerebrospinal fluid protein levels, tuberculous meningitis cannot be ruled out. Standard antituberculosis (anti-TB) therapy was given, including isoniazid 0.6 g 1/day intravenously, rifampicin 0.6 g 1/day intravenously, pyrazinamide 1.5 g 1/day orally and ethambutol 0.75 g 1/day orally. At the same time, liver protection treatment was carried out. Two days later, he had vision and restlessness at night, which was relieved by risperidone. The next morning, the patient developed severe headache and projectile vomiting. Neurological exam showed double lower limb muscle strength down to grade 3. We performed the third LP to collect CSF. His intracranial pressure was over 400 mmH2O. CSF routine test showed the protein was 34.12 g/L, the glucose was 0.15 mmol/L, the WBC count was 202*106/L and the Chloride level was 102.4 mmol/L. Metagenomic next-generation sequencing (NGS) of viral and bacterial genomes from the CSF was performed, which was positive exclusively for the normal skin flora DNA and was not significant. Xpert MTB/RIF prior, rpoB sequencing and Brucella serology were also performed, but no significant results were detected. A day later, the patient was transferred to the infectious disease hospital for further treatment.
CSF cytology specimens were performed twice and were finally positive for malignant cells (Figure 2A). We performed whole genome sequencing for MTB&NTM and full-length resistance genes sequencing by the third generation nanopore sequencing technology. Subsequently, mycobacterium abscessus have been sequenced, the number of which was 7,940. He subsequently underwent the whole-body 18F-FDG positron emission tomography/computed tomography (PET/CT) scanning. It revealed multiple hypermetabolic foci in leptomeningeal and the whole spinal cord, indicating primary meningeal malignancy with spinal cord spread. The patient was eventually diagnosed with LM and admitted to the Radiotherapy Department of our hospital on December 24, 2021. Although we actively contacted neurosurgery department of our hospital to prepare the spinal cord biopsy, the patient had a fever and died after 2 days.