Think TB! A rare case of influenza and rapid progressive neurotuberculosis coinfection

Abstract

An Indian migrant presented with increasing neurological symptoms after an acute influenza B infection. We diagnosed progressive neurotuberculosis—a rare and difficult case of tuberculosis and influenza co-infection. It highlights the importance of broad-based diagnostics in people from low- and middle-income countries, taking into account unusual manifestations of tuberculosis.

Case

A 22-year-old Indian born woman living in Germany for 1 year for her master studies presented to our emergency department with high fever for 2 days, severe generalized joint pain and headache. An Influenza B infection was confirmed and treated as an inpatient with Oseltamivir. Chest x-ray showed mild infiltrations that were attributed to influenza (Fig. 1). She was discharged after 5 days due to clinical improvement and absence of fever.

Figure 1.

Chest X-Ray.

Two days after discharge the patient was readmitted with increasing headache, leg pain, confusion and somnolence. After a generalized epileptic seizure, native cerebral computerized axial tomography (CAT) scan was unremarkable. Within two further days the patient developed right-sided abducens palsy, head stiffness, left-sided hemiparesis, and dysarthrophonia. Cerebral spine fluid (CSF) puncture revealed moderate pleocytosis and severe brain–blood barrier dysfunction with massively increased protein. Due to those findings suggesting tuberculosis an antituberculous treatment (Rifampicin, Ethambutol, Isoniazid, Pyrazinamide) supplemented by empirical therapy for viral and bacterial meningitis with amoxicillin, ceftriaxone, aciclovir and steroids was started.

CSF polymerase chain reaction (PCR) (GeneXpert MTB/RIF) was positive for Mycobacterium tuberculosis. No other pathogens could be detected by culture or PCR, therefore amoxicillin, ceftriaxone, and aciclovir were ended.

Cerebral magnetic resonance (MRI) imaging was suggestive for neurotuberculosis with diffusion impairment of the right lateral brain stem, small nodular changes of pons, cerebellar peduncle, and tentorium cerebelli with marginal contrast enhancement (Fig. 2). The brainstem lesion was suggestive of tuberculous vasculitic stroke.¹ Chest CT scan showed a cavernous mass in the right upper lobe, suggestive of pulmonary Tuberculosis (Fig. 3). Bronchoscopy was unremarkable with no evidence of open pulmonary tuberculosis. PCR, microscopy, and cultures (bronchoscopy and smear samples) remained negative for M. tuberculosis.

Figure 2.

MRI of the head.

Figure 3.

CT of the chest.

As patient’s state of consciousness improved, she reported severe leg pain with paraparesis of both legs, severe neuropathic pain of calves and thighs, and urinary retention in neurological examination. According to that, spinal MRI showed inflammatory contrast enhancement along the spinal cord, predominantly on the level of L4-S1 nerve roots, suggestive of spinal radiculo-meningitis without impairment of the spinal cord (Fig. 4). While continuing tuberculostatic therapy, a rapid increase in transaminases occurred. Isoniazid and Pyrazinamide were stopped until normalization of transaminases, and gradually added back to complete and from now on complication-free therapy.

Figure 4.

MRI of spinal column and spinal cord.

Continuing tuberculostatic therapy, tapering of steroids, and intensive early rehabilitation resulted in further clinical improvement. Almost three months later the patient was admitted to outpatient neurological rehabilitation with mild right-sided abducens palsy and sensory impairments of hands and legs, whereas paraparesis and urinary retention had largely resolved. On admission, paraparesis and urinary retention had completely resolved; there was still mild right-sided abducens palsy and sensory disturbances in the left arms. After six weeks of neurorehabilitation, symptoms further improved, and she was discharged with mild gait imbalance, able to return to work.

In summary, we diagnosed and treated a rare case of Influenza and rapid progressive spinal and cerebral tuberculosis² in a young Indian born woman. Our patient later reported having had occasional headache before Influenza infection. Thus, a pre-existing pulmonary tuberculosis with mild cerebral involvement is possible, which rapidly progressed in the course of Influenza.

Spinal and cerebral tuberculosis is a severe disease with up to 30% mortality despite treatment³ and a condition more frequently seen in low- and middle-income countries, especially in patients with HIV-Coinfection. There is less data on tuberculosis/influenza-coinfection available. More severe courses of tuberculosis have been shown in cases of co-infection,⁴ still the findings remain controversial.⁵

Due to climate change, both migration movements and the spread of previously exclusively tropical diseases will continue to increase. This case highlights the importance of broad interdisciplinary diagnostics especially in a growing number of migrants from low- and middle-income countries that can present with uncommon signs and symptoms. Complex infections such as rare forms of tuberculosis are increasingly the cause, even in low-incidence countries as Germany.

Funding

There are no sources of funding.

Author Contributions

Jakob Schroeder (Conceptualization-Lead, Investigation-Lead, Project administration-Lead, Visualization-Lead, Writing—original draft-Lead, Writing—review & editing-Lead), Andreas Schlesinger (Supervision-Lead, Writing—review & editing-Supporting), Lothar Burghaus (Supervision-Supporting, Writing—review & editing-Supporting), Pantea Pape (Supervision-Supporting, Writing—review & editing-Supporting), and Maryam Balke (Conceptualization-Supporting, Investigation-Equal, Writing—original draft-Supporting, Writing—review & editing-Equal).

Conflicts of Interests/Author statements

There are no conflicts of interests by none of the authors.

Consent from patient

Written consent of patient had been obtained.