CANDIDATE OF MEDICINE, SENIOR RESEARCHER OF THE DEPARTMENT OF NEUROINFECTIONS OF L. HROMASHEVSKYI INSTITUTE OF EPIDEMIOLOGY AND INFECTION DISEASES OF THE NATIONAL ACADEMY OF MEDICAL SCIENCES OF UKRAINE

Abstract

Background. Central nervous system tuberculosis is one of the most severe forms of extra-pulmonary tuberculosis. Tuberculous meningoencephalitis (TBM) is highly prevalent globally in resource-limited countries and in patients with immunosuppression. We present here a case of meningoencephalitis with proved acute Herpes simplex virus infection. However, our patient responded to antituberculosis therapy. This raises the possibility that some cases of “idiopathic” (cryptogenic) meningoencephalitis may represent occult tuberculosis disease.

Result. A 22-year-old woman was admitted to our hospital because of fever, headache and hallucinations. Neck stiffness and other meningeal symptoms were present. CSF examination showed lymphocyte-dominant pleocytosis and a decreased level of glucose. Both Herpes simplex virus type 1 (HSV-1) DNA and IgG antibodies to the virus were found in the CSF sample. Although antibiotics and acyclovir were administered, fever, disturbance of consciousness, hallucinations and meningeal signs intensified. A second CSF sample obtained a week after the collection of the first one contained higher level of cytosis and so called “spider-web” cloth (SWC). As a result, the diagnosis was revised: tuberculosis was regarded as the most likely cause of the disease. The patient started receiving antituberculous treatment. Soon after the medications were changed, the meningoencephalitis started to subside and was finally cured. Judging from the clinical features, the CSF and MRI findings, the effectiveness of antituberculous drugs, the final diagnosis was made as tuberculous meningoencephalitis. From all these things, we conclude when even antibodies for Herpes viruses and viral DNA are present in the CSF of the patient with sterile meningoencephalitis the possibility of latent involvement in the process of Koch bacteria (KB) should be kept in mind.

Conclusion. The patient’s symptoms and signs began to resolve with antituberculous therapy. Resolution of the lesions was confirmed by magnetic resonance imaging. We conclude that this case represented occult tuberculous disease. An empiric trial of antituberculous therapy may be used in other cases of apparently idiopathic meningoencephalitis.