Step by step review of a case

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The patient is a 43-year-old Asian man who has never smoked or consumed alcohol in his life.

The patient had a history of high blood pressure and was working as a supervisor and warehouse manager.

The patient complained of muscle pain and headache for three months.

No abnormality was found in the examination and examination of the cardiovascular and respiratory system.

The patient had no lymphadenopathy or organomegaly.

Complete blood count, electrolytes, urinalysis, and liver function tests were normal, and the patient had a negative quantiferon test. The patient’s initial CXR was normal.

The patient underwent bronchoscopy, which was positive for acid-fast bacillus in the lavage performed. Anti-tuberculosis treatment was started for the patient and he was discharged.

Two weeks later, the patient presents with morning headaches and lethargy. The patient’s wife stated that the patient had memory problems and personality disorder and was completely surprised by his depression.

In the neurological examination, mild paralysis of the 6th nerve was determined.
Brain MRI revealed multiple tuberculomas.
In the examination of CSF, protein was 500 mg/dl, glucose was less than 15 mg/dl, and the count of lymphocytes was about 400 cells per microliter.

The patient is treated for CNS tuberculosis.
The patient was HIV negative.

A week later, the patient is discharged with oral corticosteroids and tuberculosis treatment.

Three days later, the patient presents with lower motor neuron paralysis and bladder dysfunction.

And emergency MRI of the spine showed multiple tuberculomas in the spinal cord. Although the patient was treated with glucocorticoid and anti-TB drugs, he did not recover.

Rituximab was started for the patient. The patient’s symptoms improved significantly and muscle strength returned in his lower limbs. The patient continued to recover well and responded to treatment.

There is very little evidence in the literature regarding the use of Rituximab in TB.

Important points:
1- CNS tuberculosis mimics other CNS lesions, especially tumors in symptoms and imaging
2- The mucinous behavior of tuberculosis in the patient, so that despite the negative pulmonary imaging and tests and quantiferon test, the bronchial lavage was finally positive.
3- Persistence in not leaving the patient with a chronic cough, even if it is mild, with a good general condition and negative initial tests.
4- Interesting and quick effect of rituximab
5- Serious treatment and quick reaction to the patient’s new neurological symptoms and not wasting time with the aim of preventing the patient’s condition from becoming critical or creating a permanent neurological lesion.

Source:
The case mentioned by Dr. Ershadi (general practitioner).
Rural insurance family doctor
Rural Center of Shahriar Health Center
In the Amurshi tour on Fridays in the stop tb group

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This post is written by Majidrezaei610