A case of miliary tuberculosis with tuberculous meningitis in intensive care

Abstract

Tuberculosis (TB) is one of the commonest causes of death due to infection worldwide. Miliary tuberculosis (MTB) is very rare in the intensive care unit (ICU) and carries a significant risk of death. This case report describes the presentation and management issues of MTB along with TB meningitis in ICU. Case report A 42-year-old Afro-Caribbean lady presented to the hospital with a two-month history of non-productive cough, shortness of breath and generally feeling unwell with progressive deterioration. Chest X-ray revealed bilateral interstitial shadowing. Bronchial washings were positive for mycobacterium tuberculosis confirming the diagnosis of MTB. Blood results revealed anaemia and deranged liver function. An abdominal ultrasound scan demonstrated multiple liver abscesses consistent with TB of the liver. She developed severe respiratory failure necessitating mechanical ventilation on ICU. She was commenced on four drug anti-tuberculosis therapy (ATT). During her long stay in ICU repeated attempts to wean her off the ventilator failed due to worsening respiratory failure. Even attempts to wean her off sedation failed due to increased agitation. She failed to absorb enteral feed, which meant her ATT had to be given parenterally. On day 50 on ICU, due to increasing agitation, a CT of her head was performed. This demonstrated a low density lesion with generalised meningeal enhancement, suggestive of cerebral tuberculoma and TB meningitis. She was started on high dose steroids according to British Thoracic Society and NICE guidelines [1]. Within 24 h of commencing steroids she improved dramatically and was discharged to the ward within a week. Discussion MTB is a form of progressive tuberculosis resulting from lympho-haematogenous spread of pulmonary or extra pulmonary focus. MTB forms 1-2% of all cases of TB [2]. Predisposing factors include old age, immunosuppression, malnutrition, HIV and steroids. It affects organs including the lungs, liver, adrenals, meninges, brain and spine. TB meningitis is seen in 10-30% of adult patients with MTB [2]. An early CT head and lumbar puncture is essential for diagnosis of meningeal TB. All cases of MTB should be started on the standard four drug treatment [1]. Although ATT is the cornerstone in the management of MTB, addition of steroids is beneficial in the treatment of meningeal TB. Despite controversy, corticosteroids are found to be useful in meningeal TB [3] especially for severe meningitis. This case report clearly demonstrates the benefits of steroids in the treatment of meningeal TB.