Miliary Tuberculosis in an Immunocompetent Patient Presenting with Tuberculous Meningoencephalitis Complicated by Hydrocephalus and Seizures

Abstract

Miliary tuberculosis (MTB) is a disseminated form of tuberculosis (TB) arising from the lymphohematogenous dissemination of Mycobacterium tuberculosis bacilli followed by millet seed-sized tuberculous foci. It mainly affects immunocompromised patients and can lead to severe complications or even death. The clinical manifestation is diverse and depends on the organ affected, the patient's immune status, and the possible involvement of the central nervous system (CNS). Hence, this case report presents a case of an immunocompetent male with a decreased level of consciousness and convulsions requiring admission to the intensive care unit. The patient was diagnosed with MTB, meningoencephalitis, hydrocephalus, and severe hyponatremia. He subsequently improved after a short period of initiation of anti-TB medications. This report also highlights the clinical features of MTB and reviews the literature on associated CNS complications of MTB.

Keywords: Hydrocephalus; MTB; immunocompetent; meningoencephalitis; tuberculous meningitis.

Figure 1

(a and b) Chest X-ray on admission (a) shows bilateral disseminated fine reticulonodular infiltration (arrows) with “tiny millet seed-sized nodules.” Repeated chest X-ray (b) after 2 weeks of treatment showed resolved previously seen diffuse uniform-sized small nodules opacities in both lungs

Figure 2

(a and b) Computed tomography of the head without contrast showed supratentorial ventricular enlargement (arrows) suggestive of hydrocephalus. CT: Computed tomography

Figure 3

(a and b) Axial fluid-attenuated inversion recovery (FLAIR) shows supratentorial lateral ventricle dilatation and subarachnoid FLAIR hyperintensity at cerebral hemispheres, representing meningitis (white arrows). There are multiple bilaterally scattered focal areas of high FLAIR signal intensity involving cortical/juxtacortical, subcortical, and periventricular white matter of both cerebral hemispheres and posterior fossa structures, with no surrounding vasogenic edema, likely representing granulomas (yellow arrows)