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TB or not TB?
  1. Christopher Kobylecki1,2,
  2. Emily Montague3,
  3. Tom Blanchard4,
  4. Rekha Siripurapu5,
  5. David McKee1
  1. 1 Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK
  2. 2 Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, UK
  3. 3 Leeds Teaching Hospitals NHS Trust, Leeds, UK
  4. 4 Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK
  5. 5 Department of Neuroradiology, Salford Royal Hospitals NHS Trust, Salford, UK
  1. Correspondence to Dr Christopher Kobylecki, Neurology, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK; christopher.kobylecki{at}manchester.ac.uk

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A 37-year-old man of Pakistani origin gave a 2-week history of worsening headache, confusion and seizures. He had recently returned from a trip to Pakistan. His only previous medical history was retinitis pigmentosa. On initial examination, he was feverish and photophobic, with no focal neurological deficit.

An initial CT scan of head showed basal ganglia calcification but no other parenchymal changes. Cerebrospinal fluid (CSF) showed raised protein (0.97 g/L), low glucose (2.8 mmol/L compared with plasma glucose of 8.1 mmol/L) and a lymphocytic pleocytosis of 138×106/L. CSF opening pressure was not documented.

Question 1: What is the most likely diagnosis and how should he be managed?

Acutely altered mental state, headache, fever and seizures should raise suspicion for central nervous system (CNS) infection, in particular meningoencephalitis. The CSF findings, ethnic origin and travel history strongly suggest tuberculous (TB) meningitis; we started rifampicin, isoniazid, pyrazinamide and moxifloxacin, together with dexamethasone, initially 24 mg/day according to British Infection Society guidelines. His seizures settled with levetiracetam. His baseline chest radiograph was normal. MRI scan of brain showed non-enhancing high T2 signal lesions in the left mesial frontal lobe and right parieto-occipital region (figure 1).

Figure 1

MR scan of brain at presentation. (A, B) Axial T2-weighted images showing high signal in the mesial frontal regions. Coronal FLAIR image showing high signal in mesial frontal (C) and right parieto-occipital region (D). FLAIR, fluid-attenuated inversion recovery

Question 2: What is the differential diagnosis of his MR brain appearances?

Infective causes are the most likely at this stage, including TB meningoencephalitis and viral encephalitis. The initial imaging does not show the meningeal enhancement or tuberculomas that can occur in TB meningitis. Neoplastic causes such as CNS lymphoma are possible, although the subacute presentation is atypical and there would usually be contrast enhancement. Neuroinflammatory causes are also in the differential diagnosis, with many potential causes.

We continued anti-TB treatment and gradually reduced the dexamethasone dose. Five days later, his CSF had improved, …

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