P 1092. The Challenging Nature of Cerebral TBC Manifestations in Children and Young Adults

Background: The challenging nature of cerebral TBC manifestation in children and young adults.

Goals: The goal of this case study is to present the clinical course of a cerebral and abdominal TBC manifestation and to outline the tremendous challenges regarding the interpretation of clinical symptoms, laboratory and radiological diagnostics, and therapeutic decisions.

Leading Question: How does extrapulmonary TBC manifest itself in children and young adults and what diagnostic and therapeutic measures are necessary?

Case Report: We present the case of a 17-year-old male patient born in Germany. His father was diagnosed with TBC in 2002. Clinical symptoms that led to hospital admission twitching of the right hand and leg with consecutive generalized tonic-clonic seizure and loss of consciousness. Anticonvulsive therapy with levetiracetam was initiated. cMRI revealed a left parietal mass suspected to be an abscess due to dental root inflammation. Within the interdisciplinary discussion, the suspicion of a tuberculoma with combined meningeal involvement was postulated.

Meanwhile, RT23-skin test revealed a significant induration of 20 mm after 72 hours. The quantiferon testing was highly positive with TB1/2-NK at >10 IU/mL.

Radiological diagnostics via sonography and MRI revealed significant ascites and peritonitis, dilation of small intestinal bowels, and ileus. Chest X-ray showed no sign of pulmonary TBC manifestation. EEG showed subcortical pathology, without seizure-like potentials. Due to initial seizure, levetiracetam was started.

Laboratory work: Negative TBC-PCR’s/cultures for gastric juice/sputum/blood/ cerebrospinal fluid (CSF)/ascites. Negative CSF serology for borreliosis, mycoplasma, and toxoplasmosis. Viral CSF/ascites analysis was negative as well. Stool was positive for adenovirus.

Under threefold therapy (isoniazid, pyrazinamide, rifampicin) + protionamide and additionally cefotaxime/metronidazole (with later escalation to meroneme/tobramycin) radiological follow-ups showed fast and significant regression of ascites and peritonitis. cMRI follow-ups initially showed a slowed improvement of the cerebral lesion. However, after 6 months, a significant regression of the cerebral tuberculoma could be seen.

Results/Conclusion: Due to the possible chameleon-like manifestation of extrapulmonary TBC infections in children and young adults, the TBC disease pattern continues to pose an enormous challenge to clinicians and diagnosticians. We present an interesting case of cerebral and abdominal TBC infection without pulmonary manifestations. Quantiferon and RT23 testing were highly positive. Yet, in all samples, TBC microscopy, PCR, and culture revealed consistently negative results. Under tuberculostatic therapy ascites diminished completely, the cerebral tuberculoma showed significant regression.