A Rare Case of Pulmonary Tuberculosis Predisposing to Cerebral Venous Thrombosis

Abstract

PRESENTATION OF CASEA 26-year old female, nurse by profession, with no significant past medical history and family history, was diagnosed with sputum positive pulmonary tuberculosis at an outside hospital following complaints of fever, cough, and night sweats. She was started on anti-tuberculosis treatment (rifampicin, isoniazid, ethambutol and pyrazinamide), and was on treatment for 15 days at the time of presentation. She presented to our hospital with complaints of two days of altered sensorium, headache, nausea and vomiting. There was no history of photophobia, focal sensory or motor deficits. On the day of admission, she had two episodes of generalised-tonic-clonic seizures. On examination, the patient was drowsy and disoriented with a GCS (Glasgow Coma Score) of 12/15, temperature of 99°F, pulse rate of 84/min and blood pressure of 114/84 mmHg. Physical examination showed the presence of BCG vaccination scar on the left shoulder. There were no signs of meningeal irritation, no focal deficits and optic fundus examination was normal. Physical examination was otherwise unremarkable. InvestigationsThe patient's haemoglobin was 9 g%, total leucocyte count (TLC) was 5200/mm 3, platelet count was 4.2 lakhs/mm 3 , random blood sugar was 88 mg/dL, and erythrocyte sedimentation rate (ESR) was 80 mm at the end of 1 hour. Serum electrolytes, liver and renal function tests were within normal limits. Cerebrospinal fluid (CSF) study did not show any evidence of TB meningitis. CT brain revealed features suspicious of venous infarct and hence an MRI plus MR venogram (MRV) was done which confirmed the diagnosis of cerebral venous thrombosis (Figure 1 and 2). In view of the thrombosis, coagulation profile was assessed and it revealed a PT-INR of 1.2 and aPTT of 38 seconds. The patient's thrombophilia panel showed normal anti-thrombin III, protein C, protein S and factor V levels. Antinuclear antibodies (ANA) and homocysteine levels were normal and antiphospholipid antibodies were not detected.