A Case of Disseminated Tuberculosis with Tuberculous Meningitis Presenting as Acute Reversible Hemiplegia

The most frequent manifestations of CNS (Central nervous system) tuberculosis are tuberculous meningitis and intra-cranial tuberculomas. We present a case of CNS tuberculous (TB) in non-immunocompromised adolescent who initially presented with hemiparesis and later diagnosed as disseminated tuberculosis. Clinical follow up is recommended monthly during treatment. Even after treatment completion a 6 monthly follow-up is indicated for 2 years. Clinical follow-up includes assessment of improvement of symptoms, physical examination, adherence to therapy, side effects of drugs, complications and treatment of co-morbid conditions (malnutrition, HIV). Follow-up investigations should be individualized, like liver function tests if hepatotoxicity is suspected. For CNS TB, especially tuberculomas, it is recommended to monitor with repeat neuroimaging at 3 months and 9–12 months to monitor response to treatment. According to the clinical and radiological response of the patient, treatment modification can be done. In the initial 3 months of treatment, there can be an increase in the size and number of tuberculomas (paradoxical reaction), and requires continuation of ATT with addition of steroids. Suspicion of treatment failure should be kept in mind, when lesions either increase in size or fail to decrease in size after 3 to 6 months of treatment with appropriate dosing and good adherence. It could be due to Multi Drug Resistant-TB or paradoxical reaction. Complications can be immediate like seizures, raised intracranial tension and vasculitis; short term like hydrocephalus, cranial nerve palsies and diabetes insipidus; and long term like epilepsy, cognitive disability, blindness and stroke. Surgical management in the form of ventriculo-peritoneal shunt insertion is indicated for patients at all stages of severity with hydrocephalus or raised intracranial tension not responding to ATT and steroids.