Tuberculous tales: an East London experience

Abstract

Tuberculous meningitis presents a diagnostic and therapeutic challenge, and considering its long history and increasing global incidence, the evidence base for its treatment is relatively scanty. Many UK neurologists will have little first-hand experience of this deadly condition, and if faced with a patient with possible tuberculous meningitis will find decision making less than straightforward. In parts of East London (UK) the rates of tuberculosis and tuberculous meningitis are among the highest in Western Europe, and so the neurologists and respiratory physicians at the Royal London Hospital have encountered many such patients over the years. We have found experience to be a valuable teacher and so would like to share five cases that illustrate the complexities of diagnosis and management of the disease, and complications of its treatment.

The eye is the window to the diagnosis: tuberculous meningoencephalitis with choroidal tubercle

“…Additionally, the choroidal tubercle is highly specific and corroborates the possibility of tuberculosis in cases of meningoencephalitis. Its detection should lead to a therapeutic trial in the appropriate clinical setting,4 as early treatment significantly improves outcome 2. This case underlines the importance of a thorough evaluation of the patient with altered mental status due to infections of the nervous system, including the examination of the optic fundus.…”

“…However, there is growing evidence that diabetes mellitus is an important risk factor for tuberculosis,1 especially in patients with no clear immunodeficiency. The finding of a CSF glucose concentration less than half that of the plasma glucose could have raised suspicion for the possibility of tuberculous meningoencephalitis2 in patient with lymphocytic pleocytosis (although in acute stages there might be a neutrophilic predominance), despite the only mildly raised CSF protein 2…”