Pelvic and central nervous system tuberculosis complicated by a paradoxical response manifesting as a spinal tuberculoma: a case report

Abstract

Background: The post-partum period is a risk factor for tuberculosis (TB), possibly including the period after miscarriage as illustrated here. This case demonstrates how non-specific symptoms can hide widely disseminated TB.

Case presentation: A healthy 26-year-old female with a history of recent miscarriage presented to the emergency department with non-specific symptoms of headache, abdominal pain, and sub-acute fevers. She had immigrated to the United States from the Marshall Islands 9 years prior. Two months prior to presentation she had a miscarriage at 18 weeks of pregnancy. On admission, transvaginal ultrasound revealed retained products of conception and abdominal computed tomography revealed findings consistent with tubo-ovarian abscesses and peritonitis. The obstetrics and gynecology service performed dilation and curettage (D&C) to remove retained products of conception. Acid-fast bacilli cultures from cerebrospinal fluid as well as specimens from D&C and intra-abdominal abscesses subsequently all grew TB. She was diagnosed with TB meningitis, peritonitis, endometritis, and tubo-ovarian abscesses. Her treatment course was complicated by a paradoxical response resulting in a spinal tuberculoma causing lower extremity weakness. The tuberculoma was treated with surgical decompression as well as continuation of treatment with anti-tubercular chemotherapy and steroids.

Conclusion: Disseminated and extrapulmonary TB can present with non-specific symptoms. Recognition of risk factors for TB is critical for prompt diagnostic evaluation and treatment of this deadly disease. A paradoxical reaction needs to be taken into consideration when any new neurological symptoms occur during TB treatment.

Keywords: Disseminated tuberculosis; Paradoxical reaction; Post-partum tuberculosis; Spinal tuberculoma; Tuberculosis meningitis.

Fig. 1

Timeline of the patient’s illness. RIPE therapy Rifampin, isoniazid, pyrazinamide, ethambutol

Fig. 2

Computed tomography (CT) of abdomen/pelvis demonstrating tubo-ovarian and peritoneal abscesses. A Dilated, fluid-filled fallopian tubes with rim enhancement and thickening with B an associated tubo-ovarian abscess. C Peritoneal abscesses in the anterior mid and left mid-abdomen and pelvis

Fig. 3

Magnetic resonance imaging of the brain showed A, B multiple supratentorial and C infratentorial enhancing lesions consistent with tuberculomas

Fig. 4

Stained endometrial biopsy sections. A, B Endometrial tissue with increased inflammation and necrotizing granulomas (H&E stain, 4× magnification). C Single acid-fast bacillus identified on histologic examination (AFB stain, 100× magnification). Inset image shows 467× magnified view of the acid-fast bacillus

Fig. 5

Magnetic resonance imaging showing a tuberculoma of the thoracic spine. Thoracic spine MRI showed an intradural extramedullary lesion at the level of T3/T4 invading the lateral aspect of the cord with severe mass effect and diffuse surrounding leptomeningeal enhancement throughout the thoracic spine. There was also high T2/STIR signal in the thoracic cord extending from T1-T7 levels concerning for cord edema