Tubercular Meningitis in Children: Clinical Case and Viva QnA

Clinical Case of Tubercular Meningitis in Children

Clinical Case: Tubercular Meningitis in a 4-year-old child

A 4-year-old boy is brought to the pediatric emergency department with complaints of fever, headache, and progressive drowsiness for the past two weeks. His parents report that he has become increasingly irritable and has had poor appetite over this period.

History:

• Low-grade fever for 3 weeks, becoming high-grade in the last week
• Persistent headache, worse in the morning
• Vomiting, especially in the morning, for the past 5 days
• Gradual onset of drowsiness and confusion over the last 3 days
• No history of seizures or focal neurological deficits
• BCG vaccination at birth, other vaccinations up to date
• Family history: Grandfather treated for pulmonary tuberculosis 6 months ago

Physical Examination:

• General: Lethargic, responds to painful stimuli
• Vital signs: Temperature 38.5°C, HR 110/min, RR 28/min, BP 100/60 mmHg
• Anthropometry: Weight 15 kg (25th percentile), Height 100 cm (25th percentile)
• CNS examination:
  • GCS: E3V4M5 (12/15)
  • Neck rigidity present
  • Kernig's and Brudzinski's signs positive
  • Cranial nerves: Left-sided 6th nerve palsy noted
  • Motor system: Normal tone, power 4/5 in all limbs
  • Plantar reflex: Bilateral extensor response
• Fundoscopy: Early papilledema noted
• No signs of active pulmonary disease

Investigations:

• Complete blood count: Hb 10.5 g/dL, WBC 12,000/μL (Neutrophils 70%, Lymphocytes 25%), Platelets 280,000/μL
• ESR: 65 mm/hr, CRP: 40 mg/L
• Mantoux test: 18 mm induration at 48 hours
• Chest X-ray: No active lesions, mild hilar lymphadenopathy
• CT brain: Mild hydrocephalus, basal exudates
• CSF analysis:
  • Opening pressure: 25 cm H2O
  • Appearance: Slightly turbid
  • WBC: 220 cells/μL (Lymphocytes 80%, Neutrophils 20%)
  • Protein: 150 mg/dL
  • Glucose: 30 mg/dL (simultaneous blood glucose 110 mg/dL)
  • ADA: 15 U/L
  • GeneXpert MTB/RIF: Positive for Mycobacterium tuberculosis, Rifampicin sensitive

Diagnosis and Management:

Based on the clinical presentation, CSF findings, and positive GeneXpert MTB/RIF test, a diagnosis of Tubercular Meningitis (TBM) is made. The patient is classified as Stage II TBM according to the British Medical Research Council staging.

Management includes:

1. Immediate initiation of anti-tubercular therapy (Isoniazid, Rifampicin, Pyrazinamide, Ethambutol)
2. Intravenous dexamethasone as adjunctive therapy
3. Close monitoring of neurological status and intracranial pressure
4. Supportive care including fluid management and nutritional support
5. Screening of family members for tuberculosis
6. Long-term follow-up for potential complications and neurodevelopmental assessment

Varieties of Presentations of Tubercular Meningitis in Children

Varieties of Presentations of Tubercular Meningitis in Children

1. Classic Subacute Presentation

   Characteristics:

   • Gradual onset over 2-8 weeks
   • Low-grade fever, headache, and vomiting
   • Progressive neurological deterioration
   • Meningeal signs develop late in the course
   • May present with cranial nerve palsies (especially 6th nerve)

2. Acute Meningitis-like Presentation

   Characteristics:

   • Rapid onset over a few days
   • High fever, severe headache, and altered mental status
   • Prominent meningeal signs from the beginning
   • May be confused with bacterial meningitis
   • More common in younger children and infants

3. Encephalitic Presentation

   Characteristics:

   • Predominant alteration in sensorium
   • Seizures (focal or generalized)
   • Minimal or absent meningeal signs
   • May present with movement disorders
   • Fever may be absent or low-grade

4. Stroke-like Presentation

   Characteristics:

   • Acute onset of focal neurological deficits
   • May present with hemiplegia or monoplegia
   • Aphasia or other cortical signs may be present
   • Due to tuberculous vasculitis or infarction
   • Fever and meningeal signs may be subtle

5. Brainstem Syndrome

   Characteristics:

   • Predominant cranial nerve palsies
   • May present with ophthalmoplegia, facial weakness, or bulbar symptoms
   • Ataxia or long tract signs may be present
   • Due to basilar exudates or brainstem tuberculomas
   • Hydrocephalus often coexists

Knowledge Check: Question and Answers for Medical Students & Professionals

This interactive quiz component covers essential viva questions and answers. It includes 30 high-yield viva questions with detailed answers.

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