Paroxysmal autonomic instability with dystonia in a patient with tuberculous meningitis: a case report

Abstract

Introduction: This case report describes an extremely rare combination of paroxysmal autonomic instability with dystonia and tuberculous meningitis. Paroxysmal autonomic instability with dystonia is normally associated with severe traumatic brain injury.

Case presentation: A 69-year-old man of Indonesian descent was initially suspected of having a community-acquired pneumonia, which was seen on chest X-ray and computed tomography of the chest. However, a bronchoscopy showed no abnormalities. He was treated with amoxicillin-clavulanic acid in combination with ciprofloxacin. However, nine days after admission he was disorientated and complained of headache. Neurological examination revealed no further abnormalities. A lumbar puncture revealed no evidence of meningitis. He was then transferred to our hospital. At that time, initial cultures of bronchial fluid for Mycobacterium tuberculosis turned positive, as well as polymerase chain reaction for Mycobacterium tuberculosis. Later, during his stay in our intensive care unit, he developed periods with hypertension, sinus tachycardia, excessive transpiration, decreased oxygen saturation with tachypnea, pink foamy sputum, and high fever. This constellation of symptoms was accompanied by dystonia in the first days. These episodes lasted approximately 30 minutes and improved after administration of morphine, benzodiazepines or clonidine. Magnetic resonance imaging showed an abnormal signal in the region of the hippocampus, thalamus and the anterior parts of the lentiform nucleus and caudate nucleus.

Conclusions: In patients with (tuberculous) meningitis and episodes of extreme hypertension and fever, paroxysmal autonomic instability with dystonia should be considered.

Figure 1

Axial computed tomography scan of the brain at day nine after presentation. There are contrast enhancement of (a) the right caudate nucleus, (b) the right medial geniculate nucleus and thalamus, and (c) the cerebellar tentorium. These enhancements are consistent with tuberculomas and leptomeningeal infiltration by Mycobacterium tuberculosis.

Figure 2

Axial T₂-weighted magnetic resonance imaging of our patient at day 16 after admission shows an abnormal signal at (a) the corpus callosum and right-sided caudate nucleus as well as (b) the right-sided lentiform nucleus and medial geniculate nucleus extending into the right thalamus and temporal lobe. These abnormal signals are consistent with tuberculomas and lepto-meningeal infiltration of the thalamic region and the basal nuclei by Mycobacterium tuberculosis.