Classic Tuberculous Meningoencephalitis manifestations, without lumbar puncture

Abstract

A 28-year-old man who was hospitalized with decreased consciousness.Consciousness decreased slowly since one week before being admitted to our hospital. He had headache since two months ago but became worse since two weeks ago. There were frequent nausea and vomiting for the last two months (approximately four times daily). He was often confused, had abnormal personal behaviour, and had double vision since two months ago.He often had fever, night sweat, and weight losssince two months ago. He had chronic cough since two months ago. His appetite was decreased. There was no history of head trauma, hypertension, diabetes, high blood cholesterol level, stroke and heart disease. Family history of chronic cough or tuberculosis treatment was denied. Based on physical and neurological examination, he was sub-febrile (his temperature was 37.5oC) with Glasgow Coma Scale (GCS) score total of 11(E3M5V3). Nuchal rigidity and Kernig’s sign were positive. Movement and strength were unclear lateralization at first, but then we found that there was decreased movement and strenght at the right side of the body, tone and physiological reflexes were normal. Pathological reflexes were negative. Routine and chemistry blood examination demonstrated White Blood Cell (WBC): 13.940/mm3; Red Blood Cell (RBC): 4.55x106/mm3; Hemoglobin (Hb): 13.3g/dl; Haematocrit (HCT): 38.1%; Platelet (PLT): 323x103/mm3; Blood Random Glucose: 90 mg/dl; Ureum 18 mg/dl; Creatinine: 0.52 mg/dl; SGOT: 40 mg/dl; SGPT: 79 mg/dl; Sodium: 126 mmol/L; Potassium: 4,1 mmol/L; Chloride: 90 mmol/L; HIV Rapid Test non reactive; HIV Antigen 0.03 (non reactive); and HIV Antibody 0.04 (non reactive). Axial head CT-scans of both non-contrast and contrast to the administration of intravenous gadolinium (Gd-DOTA) were performed and showed left thalamus infarct that was not enhanced by contrast injection and hypertensive hydrocephalus (obstuctive) (Figure 1A and B). A contrast head CT-Scan examination showed basal enhancing exudate