Miliary Tuberculosis with Tuberculous Meningoencephalitis in Children Under Two Years of Age with a Missed Opportunity of Immunization: A Case Report

Abstract

Miliary TB is one of the manifestations of TB with incidence 3-7% among all TB cases and 13% can spread to brain as Tuberculous Meningitis (TBM). This case report discusses a case of miliary TB complicated with meningoencephalitis in children under two years of age without history of BCG vaccination. A 23-month-old girl with severe malnutrition, came to outpatient clinic with fever for 6 months, cough for 3 months, gland enlargement in the neck, no history of BCG and no history of TB contact. Because the chest x-ray showed miliary TB, we decided to hospitalized the patient. Suddenly she had loss of consciousness and seizures in the way to pediatric ward. After being managed and stabilized, we decided do head CT scan with contrast and found multiple rim enhancing lesions, with a smooth inner outer layer. Mycobacterium Tuberculosis was detected without rifampicin resistance by Polymerase Chain Reaction (PCR) TB from sputum speciment, but not detected in liquor cerebro spinal (LCS). Cerebrospinal fluid analysis showed mononuclear cell dominant (87%). The patient was given broad spectrum antibiotic, anti-seizures drug, and intensive phase anti-tuberculosis drugs with RHZE and steroid. The patient was discharged with clinical improvement after 3 weeks of treatment but had sequelae of cerebral palsy. Early detection and appropriate management are crucial in pediatric patients with miliary TB to reduce mortality rate and prevent TBM, which can lead to permanent neurological disabilities.