PDF(Pubmed)
Abstract：
Tubercular meningitis is a rare yet devastating type of extrapulmonary tuberculosis (TB) posing great diagnostic challenges due to the nonspecific clinical presentation of the patients. Here, we present a rare diagnosis of hypertrophic pachymeningitis due to Mycobacterium tuberculosis. A 36-year-old male presented with a history of headaches and giddiness for one month. Neurological examination revealed hypo-reflexive triceps and ankle reflexes. Routine blood tests and autoimmune workup were normal. Brain MRI with contrast revealed diffuse dural thickening, focal leptomeningeal enhancement in the right temporal sulci, and enhancement in both the frontal and parietal convexity and the falx cerebri and along the tentorium cerebelli. Cerebrospinal fluid (CSF) analysis revealed elevated proteins, suggestive of aseptic meningitis. Meningeal biopsy revealed a chronic ill-formed granulomatous inflammatory lesion with occasional acid-fast bacilli, consistent with tubercular pachymeningitis. The patient was administered intravenous (IV) methylprednisolone for five days, following which the symptoms subsided. He was advised tablet prednisolone on discharge, and immunomodulation with rituximab was recommended as outpatient treatment. Hypertrophic pachymeningitis is a rare diagnosis characterized by the inflammation and fibrosis of the dura matter due to a diverse etiology. Tubercular etiology must be considered when the routine laboratory tests are negative, and the diagnosis should be confirmed by meningeal biopsy. The treatment of the underlying cause and corticosteroids remain the mainstay management of hypertrophic pachymeningitis. Hence, mycobacterial tuberculosis should be considered as a possible differential diagnosis while evaluating hypertrophic pachymeningitis, especially when the routine laboratory tests and immunological workup are negative.
摘要：
结核性脑膜炎是一种罕见但破坏性的肺外结核（TB），由于患者的非特异性临床表现，因此存在巨大的诊断挑战。这里,我们提出了由结核分枝杆菌引起的肥厚性硬脑膜炎的罕见诊断。一名36岁的男性，有一个月的头痛和眩晕史。神经系统检查显示三头肌和踝关节反射低反射。常规血液检查和自身免疫检查正常。增强脑MRI显示弥漫性硬膜增厚，右颞沟局灶性软脑膜增强，额叶和顶叶凸度以及小脑的镰刀和小脑的增强。脑脊液（CSF）分析显示蛋白质升高，提示无菌性脑膜炎。脑膜活检显示慢性不良肉芽肿性炎性病变，偶有抗酸杆菌，符合结核性硬脑膜炎.患者静脉注射（IV）甲基强的松龙5天，随后症状消退。他被建议在出院时服用泼尼松龙，并推荐使用利妥昔单抗进行免疫调节作为门诊治疗。肥厚性硬脑膜炎是一种罕见的诊断，其特征是由于多种病因而引起的硬脑膜炎症和纤维化。当常规实验室检查为阴性时，必须考虑结核性病因，诊断应通过脑膜活检证实。根本原因和皮质类固醇的治疗仍然是肥厚性硬脑膜炎的主要管理。因此，在评估肥厚性硬脑膜炎时，应考虑将分枝杆菌结核作为可能的鉴别诊断，尤其是当常规实验室检查和免疫学检查呈阴性时。
