Infectious Diseases Unit, Paediatrics Department, Hospital Dona Estefânia, Central Lisbon Hospital, Lisbon, Portugal; Neuroimaging Department, Hospital Dona Estefânia, Central Lisbon Hospital, Lisbon, Portugal; Neurology Unit, Paediatrics Department, Hospital Dona Estefânia, Central Lisbon Hospital, Lisbon, Portugal.
- Port J Pediatr 2018;49:367-8. DOI: 10. /APP.2018
6 month old baby admitted with a fever of 39.2ºC, apnoea, bradypnoea and convulsive status epilepticus. A brain computer tomography and subsequently a brain magnetic resonance revealed ischaemic stroke involving all of the territories of the anterior, middle and posterior cerebral arteries to the left and part of the territory of the perforating branches to the right, with leptomeningeal captures, predominantly basal and heterogeneity of the cerebrospinal fluid (CSF). The anterior fontanelle was domed and hypertensive. A lumbar puncture revealed cloudy liquor with 64 cells/ μL with a predominance of lymphocytes, glucose 20 mg/dL, proteins 158.6 mg/dL. The baby was medicated with ceftriaxone and vancomycin without improvement. A high-risk family was identified, with drug addict parents resident in a parish of Lisbon with a high incidence of tuberculosis. The baby was not vaccinated against tuberculosis. A culture test of the blood and of the CSF were negative. Given the social and epidemiological history, characteristics of the CSF and negative culture tests, antituberculosis drugs were started. The direct test for mycobacteria in the gastric juice and a chain reaction of the polymerase in the CSF identified Mycobacterium tuberculosis, subsequently confirmed in a culture test. Evolution was towards right spastic hemiplegia, predominantly brachial and epilepsy. The typical presentation of tuberculous meningitis is classically insidious with manifestations that appear over weeks or less frequently it manifests as hydrocephaly with no apparent cause. Encephalitis or pyogenic meningitis as occurred in this case, are rare, but possible, forms of presentation. Hypoglycorrhachia and high proteinorrhachia in the CSF are also present in serious bacterial meningitis, but a meningitis of the base associated to risk factors for tuberculosis should make us suspect the diagnosis.
Palavras Chave: MRI; tuberculosis meningitis; stroke