A 67-year-old Haitian male HIV-negative New York City taxi driver with a past medical history of hypertension, hyperlipidemia, Parkinson's Disease, and Type 2 Diabetes Mellitus and without recent travel history presented with four days of sudden gait ataxia associated with intermittent fevers for same duration and without any respiratory symptoms. He was initially treated at an outside facility with Vancomycin and Ceftriaxone for two days but left against medical advice. While there, the patient had a computerized axial tomography (CT) scan of the head which noted a 1.5 cm hypodense left frontal lobe focus with adjacent multiple subcentimeter hyperdensities and a CT chest which noted bilateral pulmonary tree-in-bud densities and a 1.6 cm enhancing liver lesion. On admission, the patient was tachycardic and hypertensive without leukocytosis. Physical exam was revealing for inability to walk in a straight line, lateral-veering posture, and imbalance. Chest x-ray showed pulmonary vascular congestion and CT head with intravenous contrast (IV) was significant for a 2 cm left parasagittal frontal lobe lesion (Fig. 1) suspicious for an abscess. The patient was empirically started with Vancomycin and Cefepime. Subsequent lumbar puncture (Table 1) showed albuminocytological dissociation with monocytes and lymphocytes on cytology but without malignancy. CSF culture with Gram stain, AFB smear and culture, Herpes Simplex Virus DNA PCR, MRSA nares, serum Toxoplasma gondii DNA PCR, and Treponema antibody were also negative. Additionally, QuantiFERON testing was indeterminate. Further studies with magnetic resonance imaging (MRI) of the brain with and without IV contrast showed subfalcine and supracallosal diffuse enhancements suggestive of leptomeningeal disease (Fig. 2A) with multiple lobulated foci within the arachnoid spaces consistent with an arachnoid space empyema and multiple focal cortical gray matter abscesses (Fig. 2B), while CT chest, abdomen, and pelvis with IV contrast (Fig. 3) showed bilateral pulmonary patchy ground glass opacities, a large hepatic hyperdensity, bilateral renal cortical cysts, and retroperitoneal lymphadenopathy.
The patient had continued clinical deterioration with worsening mental status and intermittent fevers. Antibiotic therapy was broadened to Meropenem. Despite broadening of antibiotics, mental status continued to decline and empirical therapy with Rifampin, Isoniazid, Pyrazinamide, and Ethambutol (RIPE) was initiated along with steroids for high suspicion of disseminated Tb with presumed MTb meningoencephalitis. Additionally, Bactrim was added for concern over Nocardia and Acyclovir for possible underlying HSV. Repeat lumbar puncture on day 4 was significant for elevated protein and WBC count (62% neutrophils, 26% lymphocytes, 12% monocytes) with lymphocytes and neutrophils on cytology but without malignancy (Table 1). Further testing including CSF culture with Gram stain, fungal culture, Cryptococcus antigen, India ink preparation, HSV DNA PCR, BK/JC virus DNA PCR, AFB smear and culture, MTb complex DNA, serum Toxoplasma, HSV, HTLV, P. Jerovicii (PJP), EBV DNA RT-PCR, Parvovirus B19 antibodies, VZV DNA RT-PCR, urine C. trachomatis and N. gonorrhoeae, and histoplasma urine antigen were all unremarkable. Additional QuantiFERON was again indeterminate. However, CSF adenosine deaminase (ADA) levels were elevated.
On day 10 of admission, the patient showed improvement in mental status while on RIPE therapy. Subsequent bronchoscopy was performed with grossly unremarkable bronchoalveolar lavage (BAL). Repeat MRI brain showed no changes from prior. Additional lumbar punctures on day 14 and day 39 (Table 1) continued to show elevated protein and WBC count, but downtrending and normalizing from prior studies. On day 42 of admission, MRI brain showed reduction of the enhancing lesions (Fig. 4) following treatment for intracranial Tb and chest x-ray no longer showed any consolidation. The patient was subsequently discharged to acute rehabilitation and outpatient follow up.
Two months after the patient's bronchoscopy was performed, as above, AFB smear from BAL culture (incubated in broth) was positive with pan-sensitive susceptibility. Overall, the patient was treated with RIPE therapy for a total of two months while hospitalized and throughout both admissions. The patient was additionally followed up at his outpatient visits showing improvement in mentation and orientation and after 121 days of RIPE therapy, he was switched to Rifampin and Isoniazid alone, which he remained on for a total of 244 days. He was treated for MTb meningitis for a total of 12 months.