Seizures, Paraplegia, and Cough Unveiling Disseminated Tuberculosis

Accepted Manuscript Seizures, paraplegia and cough unveiling disseminated tuberculosis Jean-Luc Baudel, MD, Vincent Dubée, MD, PhD, Juliette Palle, MD, Hafid Ait-Oufella, MD, PhD PII:

S0002-9343(15)00679-8

DOI:

10.1016/j.amjmed.2015.06.048

Reference:

AJM 13108

To appear in:

The American Journal of Medicine

Received Date: 22 May 2015 Revised Date:

19 June 2015

Accepted Date: 19 June 2015

Please cite this article as: Baudel JL, Dubée V, Palle J, Ait-Oufella H, Seizures, paraplegia and cough unveiling disseminated tuberculosis, The American Journal of Medicine (2015), doi: 10.1016/ j.amjmed.2015.06.048. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT

Seizures, paraplegia and cough unveiling disseminated tuberculosis

([email protected])

Dubée Vincent, MD, PhD

([email protected])

Palle Juliette, MD

([email protected])

Ait-Oufella Hafid, MD, PhD

([email protected])

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Affiliations:

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Baudel Jean-Luc, MD

médicale, Paris, F-75012, France

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Assistance Publique - Hôpitaux de Paris, Hôpital Saint-Antoine, service de réanimation

Université Pierre-et-Marie Curie, Paris, France

Corresponding author:

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Professor Hafid Ait-Oufella

Service de réanimation médicale, Hôpital Saint-Antoine 184 rue du Faubourg Saint-Antoine, 75571 Paris cedex 12

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E-mail : [email protected] Tel +33 1 49 28 23 15

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Fax +33 1 49 28 21 45

Funding: none

All authors had access to the data and a role in writing the manuscript.

Keywords: tuberculosis, miliary lung disease, meningitis.

ACCEPTED MANUSCRIPT A 22-year-old HIV-negative man was admitted to the intensive care unit after a first episode of seizures. Clinical examination revealed persistent paraplegia, the temperature was 38°C. The patient’s family reported a 6-month history of asthenia, headache, intermittent cough, and limping. Pre-contrast brain computed tomography (CT) was normal, whereas post-contrast

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imaging (panel A) revealed numerous ring-enhancing lesions without surrounding edema. Post-contrast T2-weighted medullary magnetic resonance imaging showed similar lesions in the cerebellum, the midbrain, and the spinal cord (panel B). Nodular lesions with rim

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enhancement disseminated through the central nervous system may be seen in granulomatous diseases such as tuberculosis, fungal infections, neurocysticercosis, and neurosarcoidosis

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[1,2]. Brain metastasis and pyogenic abscesses may also present as ring-enhancing lesions but are typically associated with marked perilesional edema.

Chest CT (panel C) showed a diffuse micronodular pattern suggestive of miliary lung disease with peripheral “tree-in-bud” opacities that are consistent with superimposed small airway

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infection. The findings are highly suggestive of tuberculosis. Differential diagnosis includes fungal infections such as coccidioidomycose and other granulomatous diseases such as sarcoidosis. A miliary pattern may rarely be seen in some metastatic cancers (especially

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thyroid carcinoma), but nodules are typically larger in size (> 5 mm) [3]. Finally, a body CT scan gated on bones demonstrated widening of the right sacroiliac joint

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and bony destruction of the posterior medial iliac bone with a pathological fracture (Panel D). Findings were consistent with tuberculous sacroiliitis. This multifocal disease with miliary lung involvement was highly suggestive of disseminated tuberculosis. Cerebrospinal fluid (CSF) analysis identified meningitis with a high protein (43 g/l), a low glucose (1.2 mmol/l) as well as increased leukocyte count (119 per milliliter, 67 % neutrophils, 14 % lymphocytes). Ziehl staining detected mycobacteria in the CSF and a

ACCEPTED MANUSCRIPT geneXpert MTB/RIF assay was positive for rifampicin-sensitive M. tuberculosis. A 4-drug antibiotic regimen against M. tuberculosis and corticosteroids were initiated.

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No potential conflict of interest relevant to this letter was reported.

Legend to Figure

(A) Post-contrast computed-tomography (CT) of the brain, showing multiple ring-enhancing

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lesions corresponding to tuberculous granulomas (arrows). Post-contrast magnetic resonance

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imaging (B) reveals similar lesions in the brainstem, the cerebellum, and the spinal cord (arrows). (C) Chest CT demonstrating a fine diffuse micronodular pattern with centrilobular predominance consistent with small airway infection as evidenced by peripheral "tree-in-bud" opacities (subpleural area enlargement in the window), as well as non-centrilobular fine nodules consistent with super-imposed miliary disease. (D) Pelvis CT gated on bones. The

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right sacroiliac joint demonstrates asymmetric widening with cortical destruction on both sides of the joint. There is bony destruction of the posterior medial iliac bone with a

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pathological fracture as evidenced by cortical breaks medially and laterally (arrow).

References

1. Smirniotopoulos JG, Murphy FM, Rushing EJ, Rees JH, Schroeder JW: Patterns of contrast enhancement in the brain and meninges. Radiographics 2007; 27(2): 525-51. DOI: 10.1148/rg.272065155 2. Schwartz KM, Erickson BJ, Lucchinetti C: Pattern of T2 hypointensity associated with ring-enhancing brain lesions can help to differentiate pathology. Neuroradiology 2006; 48(3): 143-9. DOI: 10.1007/s00234-005-0024-5

ACCEPTED MANUSCRIPT 3. Andreu J, Mauleon S, Pallisa E, Majo J, Martinez-Rodriguez M, Caceres J: Miliary lung disease

revisited.

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