Presenter

Dr. Swetha Devi.G, pG IInd year,

Professor:

Dr. C. Manokaran, Dr. J.Sathiyanarayanan

Abstract

Tubercular meningitis isone of the most severe forms of extrapulmonary tuberculosis with
high mortality rate. High index of suspicion and multidisciplinary approach is essential to make an early
diagnosis due the varied clinical presentation. Cranial nerve involvement in tubercular meningitis aids in
making the diagnosis an J is also a predictor of poor outcome. Here we present a case of tubercular
rneningitis who had init al manifestation of lower cranial nerve palsy.

Case report:

66 yeat oltr male presented with complaints of dysphagia of one week duration, associated
with on and off slurring of speech. Thorough neurological examination revealed decreased palatal
movement on the lefi side. In view of stridur. patient was intubated and evaluated with a provisional
diagnosis of posterior circulation stroke. Brain magnetic resonance imaging showed basal exudates which
were highly suggestive of tubercular rneningitis. Lumbar puncture was performed and cerebrospinal fluid
analysis was done which showed elevated adenosine deaminase levels which was again suggestive of
tubercular etiology. Patient was started on anti tubercular therapy and other supportive measures patient
improved symptomatically and tolerating oral feeds.

Discussion

ln the present case, lack ofheadache, neck stiffness, disturbance ofconsciousness or general
rnalaise complicated the diagnosis. Cranial nerve involvement is a common associated finding in
tubercular meningitis, u’hich commonly affects optic and abducent nerve. Tubercular meningitis
presenting as stridor is extremely rare, which can be due to either an associated rnediastinal mass or
involvement of glossopharyngeal and vagus nerve. Possibility of a rnediastinal cause of stridor was
excluded in this case by doing CT mediastinum which revealed normal study. Previous study have shown
that among tubercular meningitis with cranial nerve involvement, only 2.2Yo had involvement of ninth and
tenth nerve, which makes this case an extremely rare presentation.

Conclusion

Cranial nerve involvement can be sometimes the only presenting feature in tubercular
meningitis. Considering the fact that early initiation of treatment with respect to favourable outcome,
tubercular meningitis should be considered as one of the differential diagnosis in these kind of patients.

Keywords

Tubercular meningitis, cranial nerves, stridor