early - stage tuberculous ( tb ) meningitis has no specific symptoms , which may lead to delayed diagnosis and consequently to a worsened prognosis .
tb meningitis with dementia as the presenting symptom after intramedullary spinal cord tumor resection without meningitis symptoms or positive tests for tb has not been described . here ,
we report a fatal case with delayed diagnosis of tb meningitis after intramedullary spinal cord tumor resection .
the patient was a 77-year - old man with recurrence of gait disturbance and dysuria .
gadolinium - enhanced magnetic resonance imaging ( mri ) revealed tumor recurrence with syrinx formation ( fig .
the postoperative course was uneventful and he was discharged after regaining the ability to walk normally .
( a ) t2 mri and ( b ) gd - enhanced mri before the initial surgery ( nine years ago ) , showing the presence of an intramedullary tumor .
( a ) t2 mri after the first surgery , showing total resection of the tumor .
( b ) t2 mri four years after the first surgery , showing regrowth of the tumor .
( c ) t2 mri and ( d ) gd enhanced mri nine years after the first surgery . at 1.5 months after surgery , the patient suffered from dementia with memory loss and diminished motivation and speech in the absence of fever , and was readmitted .
tumor recurrence was not seen on mri and blood parameters did not indicate an infection ( white blood cell count [ wbc ] , 7900 /mm ; c - reactive protein level [ crp ] , 0.1 mg / dl ; erythrocyte sedimentation rate [ esr ] , 13 mm / h ) .
2b ) and mri revealed slight enlargement of the ventricles ( mild hydrocephalus ) and the patient was diagnosed with senile dementia by a psychiatrist . however , after two weeks , his symptoms progressively worsened : dementia was more severe , he became disoriented , and his temperature increased to 39c in association with a decrease in consciousness . at that time ,
the wbc count ( 12000 /mm ) , crp level ( 0.9 mg / dl ) and esr ( 42 mm / h ) were elevated , and meropenem ( 2.0 g / day ) was started . after a further one week , he became comatose and a second mri revealed further hydrocephalus - induced ventricular dilatation ( fig . 2c ) .
no tuberculosis bacteria in csf were detected in a polymerase chain reaction ( pcr ) test , -d - glucan in serum was normal , a sputum sample was negative for mycobacterium tuberculosis in a quantiferon - tb gold ( qft - g ) in - tube test , and a tuberculin skin test ( tst ) was also negative . despite the absence of findings of tb meningitis
, we suspected that this disease was present from the patient s history , and based on the relatively slow progression of symptoms and the increases in adenosine deaminase ( ada ) , cell counts and protein and the decrease in glucose in the csf .
we administered a four - drug regimen ( isoniazid , 0.3 g ; rifampicin , 0.5 g ; ethambutol , 0.75 g ; streptomycin , 0.5 g ) , but the patient died 29 days after admission .
subsequently , m. tuberculosis was detected in the second csf sample after a 28-day culture .
the patient s wife and son gave informed consent to submit this case study for publication .
we encountered a relatively rare case of tb meningitis in an elderly patient that manifested as dementia and impaired consciousness .
fever , elevation of inflammatory markers , and signs of fever , neck stiffness , and headache , which are characteristic of meningitis , were notably absent . furthermore ,
-d - glucan in serum was normal , no bacteria were detected in the initial csf , sputum was negative for mycobacterium tuberculosis in the qft - g in - tube test , and the tst was negative .
therefore , we initially assumed age - related dementia or depression , rather than fungal or tb meningitis .
common initial symptoms of tb meningitis include internuclear ophthalmoplegia and sensorineural hearing loss , but the disease may be asymptomatic . tb meningitis accounts for only 0.5% of all tb cases , but the mortality is as high as 30% because of delayed diagnosis . in previous reports , < 20% of tb meningitis infections were detected in csf cultures ; pcr had low sensitivity ( 53% ) , compared with microbiological ziehl - neelsen staining and culture methods ( 73% ) ; and the sensitivities of the qft - g and tst were 80% and 28% , respectively . in our case , these tests were negative and m. tuberculosis was detected in a the second csf sample after long - term culture , although the initial findings were negative .
thus , a definitive diagnosis of tb meningitis is difficult . in a review by thwaites
the sensitivity and specificity of the " vietnam diagnostic rule " ( table 1 ) for tb meningitis were shown to be 86% and 79% , respectively .
this rule can help in diagnosis of tb meningitis using simple clinical and laboratory data , and can be used for tb meningitis with low glucose in csf , particularly in settings with limited microbiological resources . retrospectively
, the present case had a total score 4 , which is suspicious for tb meningitis .
therefore , our case supports the effectiveness of this rule for early diagnosis of tb meningitis , especially for cases without abnormal findings .
many secondary cases develop due to a decrease in immunity caused by diabetes or a malignant tumor in the elderly , and many of these cases have no obvious active pulmonary tuberculosis .
the patient in the present case had no history of hiv , diabetes , steroid hormone treatment , or malignant tumor , but he had undergone two surgeries for an intramedullary tumor and may have been in a postoperative compromised state .
also , in spinal cord tumor surgery , csf leakage may occur after a dura mater procedure , and there is a risk of postoperative meningitis due to long - term drain placement . even if typical symptoms such as headache , fever , and stiff neck are absent , meningitis should be suspected in a patient with deterioration of consciousness and disorientation after intramedullary surgery .
the present case indicates that symptoms of dementia after intramedullary spinal cord tumor resection should first be suspected as tb meningitis , even if tests for meningitis are negative .
we propose that anti - tuberculosis therapy should be initiated immediately in cases of suspected tb meningitis prior to positive identification in culture .
 abstractearly - stage tb meningitis has no specific symptoms in patients , potentially leading to delayed diagnosis and consequently worsening prognosis . 
 the authors present the fatal case with a delayed diagnosis of tuberculous ( tb ) meningitis with dementia as the presenting symptom after intramedullary spinal cord tumor resection . 
 the medical records , operative reports , and radiographical imaging studies of a single patient were retrospectively reviewed . 
 a 77-year - old man who underwent thoracic intramedullary hemangioblastoma resection for 2 times . 
 the postoperative course was uneventful , but 1.5 months after surgery , the patient suffered from dementia with memory loss and diminished motivation and speech in the absence of a fever . 
 no abnormalities were detected on blood test , brain computed tomography and cerebrospinal fluid ( csf ) analysis . 
 a sputum sample was negative for mycobacterium tuberculosis in the quantiferon-tb gold ( qft - g ) in - tube test and the tuberculin skin test was also negative . 
 the patient was diagnosed with senile dementia by a psychiatrist . 
 however , the patient s symptoms progressively worsened . 
 despite the absence of tb meningitis findings , we suspected tb meningitis from the patient s history , and administered a four - drug regimen . 
 however the patient died 29 days after admission , subsequently m. tuberculosis was detected in the csf sample . 
 this case is a rare case of tb meningitis initially mistaken for dementia after intramedullary spinal cord tumor resection . 
 symptoms of dementia after intramedullary spinal cord tumor resection should first be suspected as one of tb meningitis , even if the tests for meningitis are negative . 
 we propose that anti - tuberculosis therapy should be immediately initiated in cases of suspected tb meningitis prior to positive identification on culture . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONFLICT OF INTEREST