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Unusual association of tuberculous meningitis and cerebral toxoplasmosis in a HIV-negative patient. Case report

Abstract number: 1733_1115

Slavcovici A., Marcu C., Lupse M., Itu C., Carstina D.

Objective: To underline the concordance/discordance of aetiologic diagnosis with neuroimagistic assesments.

Case report: A 7-year-old child, with prolonged neonatal jaundice, non-investigated and without any subsequent results, was admitted in our clinic for high fever, headaches, vomiting, second degree coma, nuchal rigidity and left hemiparesis. The cerebral magnetic resonance imaging (MRI) was negative. The examination of the cerebrospinal fluid (CSF) revealed discreet lymphocytic pleocytosis, a moderately increased protein concentration and a very low glucose level (12 mg%), suggesting a tuberculous meningitis. The usual CSF cultures, Gram stain and Ziehl–Neelsen stain examinations were negative, as well as the HIV test. After doing CSF culture using MB/BacT system, a specific tuberculostatic therapy was initiated (isoniasid, rifampicin, ethanbutol, pyrazinamide), associated with cerebral depletion (manitol), dexamethasone, and vitamins B1 and C. 30 days later, the M. tuberculosis strain was isolated and identified with susceptibility to classical antituberculosis drugs. The clinical status worsened with the persistence of the fever, coma and the neurologic signs, and with the occurrence of seizures. After 14 days of treatment, the neuroimaging assesment (cranial CT) described important cerebral edema and multiple round hypodensity areas in the frontal and parietal lobes, and in the caudatus and lentiform nucleus; these findings needed other serological examinations. Toxoplasmosis Ig M antibodies were detected in high level (ELISA method). We reevaluated the diagnosis as a proven tuberculous meningitis and a probable cerebral toxoplasmosis, with unknown time of infection, which might be either a recent one, or a reactivation of a congenital one. The treatment was continued with antituberculosis drugs in association with trimethoprim/sulfamethoxazole, pyrimethamine and folinic acid. The adjunctive therapy consisted of cerebrolisine, and vitamins B1 and C. After 4 days of antituberculosis and antitoxoplasmosis treatment, the outcome was rapidly favourable, without fever and with substantial remission of the neurological signs.

Conclusions: The risk factor for cerebral toxoplasmosis was the immunodepression induced by M. tuberculosis. The association of mycobacterial infection with cerebral toxoplasmosis in a HIV negative patient is rare. The importance of cranial CT in an unfavourable evolution of the central nervous system infections is relevant.

Session Details

Date: 31/03/2007
Time: 00:00-00:00
Session name: European Society of Clinical Microbiology and Infectious Diseases
Subject:
Location: ICC, Munich, Germany
Presentation type:
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