| Identifier |
walsh_2022_s1_c4 |
| Title |
Is the Treatment Working? Yes, the Patient Is Getting Worse! |
| Creator |
Walid Bouthour, Heimo Steffen |
| Subject |
Neurotuberculosis; Tuberculosis; Abscess; Compressive Optic Neuropathy; Optic Tract |
| History |
A 46-year-old woman from Gambia with no prior medical history presented to the ophthalmology clinic for progressive; blurred vision, headache, and weight loss over the past two months. Her best corrected visual acuity was finger count in the; right eye and 20/20 in the left eye. There was an asymmetric optic disc swelling that was minimal (Frisén grade I) in the; right eye with temporal pallor, and marked (Frisén grade IV) in the left eye. She had complete left oculomotor and; abducens palsies. The brain MRI revealed a right frontal-temporal parenchymal mass with peripheral enhancement, and; enhancement of the intracranial portion of the right optic nerve, and of the cisternal portion of the left oculomotor nerve.; The patient had a complete neurosurgical resection of the parenchymal lesion. The polymerase chain reaction (PCR); amplification was positive for sensitive and specific genetic elements of Mycobacterium tuberculosis (IS6110 and mtp40; sequences, respectively). The mycobacterial culture confirmed the diagnosis of tuberculous intracerebral abscess, and the; antibiogram ruled out resistance to first-line anti-tuberculous drugs. The patient received a combined oral treatment of; rifampicin, isoniazid, pyrazinamide, and ethambutol, and a daily dose of 40 mg oral prednisone. After three months, the; oculomotor and abducens palsies had fully recovered. However, four months after the initiation of treatment, a follow-up; MRI showed new left prepeduncular nodules with peripheral enhancement, in contact with the left optic tract, and signs of; central nervous system vasculitis. The visual field of the left eye showed right hemianopia. The urinary detection of; isoniazid was steadily positive on monthly follow-up visits, and blood levels of isoniazid and rifampicin were within therapeutic targets. The lumbar puncture showed elevated protein (3.31 g/l) in the cerebrospinal fluid, and pleocytosis; (199000/l), without mycobacterial material. The thorax and abdomen CT showed regression of initially enlarged lymph nodes. |
| Disease/Diagnosis |
Optochiasmatic tuberculomas caused by paradoxical reaction in a 46-year-old patient, two-months after initiation of; antibiotic treatment for parenchymal tuberculous abscess |
| Date |
2022-02 |
| References |
1. DeLance A R, Safaee M, Oh M C, et al. Tuberculoma of the central nervous system. J Clin Neurosci.; 2013;20(10):1333-41.; 2. Singh A K, Malhotra H S, Garg R K, et al. Paradoxical reaction in tuberculous meningitis: presentation, predictors; and impact on prognosis. BMC Infectious Diseases. 2016; 16:306.; 3. Joseph M, Mendonca T M, Vasu U, Nithyanandam S, Mathew T. Paradoxical growth of presumed optochiasmatic; tuberculomas following medical therapy. JAMA Ophthalmology. 2013; 131(11):1463-7. |
| Format |
application/pdf |
| Type |
Text |
| Source |
54th Annual Frank Walsh Society Meeting |
| Relation is Part of |
NANOS Annual Meeting 2022: Walsh Session I |
| Publisher |
Spencer S. Eccles Health Sciences Library, University of Utah |
| Rights Management |
Copyright 2022. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright |
| ARK |
ark:/87278/s6je58r6 |
| Contributor Primary |
Walid Bouthour, MD |
| Contributor Secondary |
Heimo Steffen |
| Setname |
ehsl_novel_fbw |
| ID |
2100232 |
| Reference URL |
https://collections.lib.utah.edu/ark:/87278/s6je58r6 |
