Emergent of Multiple Intracranial Nodules Amidst Treatment for Pott's Disease: A Diagnostic Challenge

Abstract Introduction Tuberculous meningitis comprises approximately 5% of extrapulmonary tuberculous cases, and a tuberculoma is the least common manifestation of central nervous system tuberculosis. Commonly solitary, tuberculomas may also present with multiple lesions in 15-33% of cases. Neurologic symptoms may present without significant systemic manifestation, and a high index of suspicion must always be exercised in dealing with meningitis for it carries a high risk for morbidity and mortality when not adequately treated. Case presentation A 22-year-old male from the Philippines was admitted for recurrent headaches while on treatment for Pott's disease. 1 year prior to admission (PTA), the patient underwent a pre-employment health examination when pulmonary tuberculosis (TB) was noted on chest x-ray. Sputum smears confirmed the diagnosis, and the patient was treated with HRZE/HR for 6 months with good compliance. 5 months after treatment completion, he developed back pain and difficulty ambulating, with no resolution after analgesics. Magnetic resonance imaging (MRI) revealed paravertebral abscesses in T12 and L1, and biopsy revealed Pott's disease. The patient was restarted on a TB regimen and started physical therapy. 2 weeks PTA, the patient had headache in the frontal area, throbbing, 6-7/10 in intensity accompanied by fever, projectile vomiting, and night sweats. MRI of the brain revealed multiple enhancing intracranial nodules. Patient was managed clinically as neurocysticercosis versus schistosomiasis, and was discharged stable with Dexamethasone, Albendazole and Praziquantel. However, the patient developed seizures and headaches persisted with increasing frequency and intensity. On examination, the patient had weakness of bilateral lower extremities, nuchal rigidity, Budzinski's sign and Kernig's sign. Lumbar tap was done, obtaining 6cc of yellowish cerebrospinal fluid (CSF) with increased opening pressure of 29cm H20. Mannitol and Dexamethasone were started. CSF Cryptococcus, India Ink, Bactigen (Group B streptococcus, H. influenzae, N. meningitidis, E. coli), and Kato-Katz smear all showed negative results. CSF sample had low sugar and high protein with lymphocyte predominance consistent with TB meningitis. Acid-fast bacilli stains were positive. The patient was treated with Levofloxacin, Pyrazinamide, Pyridoxine, Cycloserine, Kanamycin and Prothionamide due to multi-drug resistance patterns. The patient improved and completed treatment with no sequelae. Conclusion Despite ongoing treatment for tuberculosis, it is imperative to rule out tuberculous meningitis in cases when patients present with meningeal irritation, severe headache, seizures and focal neurologic deficits. Lumbar tap is imperative as radiologic findings are nonspecific, and may mimic other entities such as neurocysticercosis, schistosomiasis, toxoplasmosis, malignancy, or abscesses.