gms | German Medical Science

Objective: Tuberculous meningitis (TBM) is a major and life-threatening extrapulmonary complication of tuberculosis. The incidence of cerebral infarction in childhood TBM ranges from 13% to 53%. Cerebral infarction in TBM is caused by a panarteritis, which consequently leads to an arteriopathy with ischemic events. In the present case, we report on an 11-month-old child with TBM who suffered from a malignant left-sided cerebral infarction and was treated by decompressive craniectomy. Further, a review of the relevant literature is presented.

Methods: Clinical case presentation, mid-term follow-up and review of the present literature.

Results: An 11-month-old girl was referred to the hospital due to high fever up to 40°C and severe pneumonia. 2 weeks after initiation of antibiotic therapy the patient presented with right-sided focal seizures. Cerebral MRI revealed several small ischemic lesions in the left insular area. 3 days later the clinical status further deteriorated with loss of consciousness. Consequent MR imaging showed in addition to massive perivascular inflammation around the circle of Willis a space-occupying complete territorial infarction of the left MCA, which made immediate decompressive craniectomy necessary. Microbiological analysis of the bronchoalveolar lavage and liquor specimen then verified pulmonary tuberculosis with tuberculous meningitis. Therapy was initiated with pyrazinamid, rifampicin, isoniazid and streptomycin. The postoperative course was uneventful with good neurological improvement and the patient was transferred to a pediatric rehabilitation clinic. At the six months follow-up the child is alert with a mild palsy of the right arm and further improvement of speech. The MRI study ruled out further ischemic lesions and a complete restitution of the perivascular inflammation.

Conclusions: We present a case of a subacute inflammatory cerebral infarction of the left MCA caused by an arteriopathy due to TBM in an 11-month-old child. Due to a life-threatening neurological deterioration, decompressive hemicraniectomy was necessary and led, combined with a strict tuberculostatic therapy, to a good neurological outcome. Since pulmonary tuberculosis and TBM were diagnosed secondarily to the ischemic events, inflammatory cerebral infarction in severely ill children should always be seen as a possible cause of an infection with mycobacterium tuberculosis.