Neurotuberculosis in an infant: a diagnostic challenge

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Abstract

Case Presentation: A 7-month-old male infant presented to the hospital with a 15-day history of diarrhea associated with anorexia and irritability. After 3 days, the parents brought the child back to the hospital due to the persistence of the symptoms and loss of the ability to sit up by himself. He was born by vaginal delivery, Apgar 9-9, without pre ou perinatal complications, gestational age of 38 weeks, updated vaccination schedule. At admission, his physical examination was normal, except for mild signs of dehydration and mucosal pallor. Laboratory tests showed hypochromic, microcytic anemia and leukocyturia on urinalysis, empirically started ceftriaxone at the usual dosage and supportive care. After seven days receiving antibiotic therapy, the patient presented meningeal signs. Initial investigation showed a thoracic X-ray with a hyperdense opacification of the upper lobe of the right lung; and a cranial CT-scan evidenced enlargement of the lateral ventricles and multiple brain images in regions of the nucleus of the base on the left, occipital on the right and in the cerebellar hemispheres with annular enhancement and signs of cerebrospinal fluid (CSF) flow obstruction. Ventriculoperitoneal shunt was performed and, subsequently, external ventricular shunt, and laboratory exams and cultures were collected. Started RIP scheme and amphotericin. CSF analysis was negative to Alcohol acid resistant bacilli, Cryptococcus, syphilis, cysticercosis, and other bacterial and fungal infections. Cultures were negative both in blood and in CSF. CSF adenosine deaminase level was normal. Serologies for HIV and TORSCH negatives. It was collected three gastric samples, and the third one was positive for Mycobacterium tuberculosis. After the introduction of the treatment with RIP, there was an evident clinical improvement, and he was discharged after 18 days.

Discussion: Neurotuberculosis is a severe form of tuberculosis disease and its clinical presentation can be pleomorphic among pediatric patients. Laboratory exams associated with clinical findings are important to better define diagnosis and therapeutic management that are crucial to improve prognosis.

Final Comments: Neurotuberculosis is a clinical challenge to the pediatricians due to its nonspecific clinical picture that must be taken into consideration in the differential diagnosis of these infants, since the earlier the diagnosis and correct treatment are initiated, the better is the prognosis.

Publication History

Article published online:
12 May 2025