Worsening of longstanding headaches, dizziness, visual symptoms • Dx?

Obtain sputum samples for all patients with extrapulmonary TB

The CDC recommends sputum sampling for all patients with extrapulmonary TB, even in the absence of pulmonary symptoms or radiographic findings, to determine the level of infectivity and potential need for a contact investigation.⁷

Due to low sensitivity of currently available rapid diagnostic tests and high mortality associated with delayed treatment, initiation of empiric treatment is recommended when the probability of CNS TB is high.⁵

Initiation of empiric treatment is advisable when the probability of CNS TB is high.

Treatment duration for CNS tuberculomas is based on one randomized controlled trial,⁸ a small number of observational studies, a prospective cohort study looking at radiographic resolution,⁹ and expert opinion. Treatment recommendations often do not distinguish CNS tuberculomas from TB meningitis.¹⁰ CNS tuberculomas are commonly treated with a minimum of 12 months of therapy, generally using the same medications and dosages used in the treatment of pulmonary TB, starting with 4 first-line agents: isoniazid, rifampin, pyrazinamide, and ethambutol. Modification of the treatment regimen may be made once sensitivities are available.¹⁰

Our patient. After cultures were determined to be pan-sensitive, our patient’s treatment regimen was simplified to rifampin and isoniazid, which she continued for the remainder of her treatment course. Her treatment was discontinued after 18 months when quarterly MRIs showed stabilization of the tuberculomas (FIGURE 2).

Following her surgery, she was started on levetiractam for seizure prophylaxis. She subsequently had a seizure on 2 occasions when the medication was discontinued or decreased, so we chose to continue it. The patient is asymptomatic from her disease with no residual deficits.

THE TAKEAWAY

A change in headache patterns in a patient over the age of 50 is a red flag that warrants imaging. In patients from countries where TB is endemic,¹¹ consider neurotuberculosis in the differential diagnosis of worsening headaches and progressive neurologic symptoms.

A diagnosis of CNS TB can be difficult and requires a high level of clinical suspicion, but early diagnosis and treatment of neurotuberculosis can minimize the high risk of morbidity and mortality. Treatment for TB shouldn’t be withheld in cases in which there’s a strong clinical suspicion for TB, but for which a definitive diagnosis is still pending.