Keywords
tuberculomas - shunt tube - ventricular catheter - chemotherapy
Introduction
The diagnosis of tuberculous meningitis is suspected in any case of subacute meningitis,
presenting in an endemic area, with a cerebrospinal fluid analysis of predominant
lymphocytes (100–500 cells/mm3) and elevated protein value (100–500 mg/dL), and hypoglycorrhachia.[1] Eighty percent of patients with tubercular meningitis develop hydrocephalus in which
65% of patients need cerebrospinal fluid (CSF) diversion.[2] Two-third of patients belong to pediatric age group in which majority of them are
males. We present a unique case of tubercular meningitis, which had dissemination
of tubercular bacilli along the ventricular end of the shunt, even while on antitubercular
chemotherapy.
Case Report
An 8-year-old male child presented with a history of blurring of vision and headache
for the last 4 months and imbalance and giddiness for the last 4 months. Previously,
patient was diagnosed as having tubercular meningitis on CSF analysis and was shunted
by right parietal Ventriculoperitoneal (VP) shunt 3 years back at another institute
for hydrocephalus ([Fig. 1]). Patient had received full dose of chemotherapy of isoniazid, rifampicin, streptomycin,
and pyrazinamide as per weight at that time. On investigation, patient had features
suggestive of shunt dysfunction and it was seen that the shunt tube was partially
in the parenchyma. At surgery, this previous shunt tube could not be removed due to
adhesions and a left-sided VP shunt surgery was performed. The patient improved after
VP shunt with visual acuity and headache improving. After remaining asymptomatic for
1 month, patient again presented with altered sensorium. Magnetic resonance imaging
brain was performed and it was seen that the patient had developed tuberculomas along
the ventricular end of his right-sided VP shunt ([Fig. 2]). The patient was started on second-generation antitubercular treatment and steroids
and there was clinical response to the above-mentioned regimen. Patient improved symptomatically
and was discharged for follow-up at 3 months.
Fig. 1 Computed tomography brain showing hydrocephalus prior to ventriculoperitoneal shunt.
Fig. 2 Magnetic resonance imaging brain with contrast showing multiple tuberculomas along
the shunt tube track.
Discussion
There is a definite pathogenetic correlation between the occurrence of tubercular
meningitis and tuberculomas. On magnetic resonance imaging, tuberculomas appear hypo
to isointense on T2-weighted imaging, rim-enhancing lesions on post-contrast T1-weighted
imaging ([Fig. 2]), and hyperintense signals on diffusion-weighted imaging. A fatal case of tubercular
bacilli dissemination through ventriculoatrial shunt, causing recurrent miliary tuberculosis,
has been reported earlier. A case of caseous granuloma at the peritoneal end of a
VP shunt has also been reported.[3] Hence, the prosthesis-induced bacilli transmission and spread have been documented
earlier. However, the persistence of bacilli after 1 year of chemotherapy is noteworthy.[2]
Our case had tubercular meningitis and dissemination intraparenchymal along a nonfunctional
shunt tube is a noteworthy finding and has not been reported in literature.
Conclusion
Tubercular bacilli may persist in spite of full dose of chemotherapy. A latent period
of 2 weeks may be provided, before inserting shunt, so as to minimize the chance of
bacilli dissemination. Wherever possible, a nonfunctioning shunt prosthesis should
be excised to avoid such an untoward complication.
