Longitudinally extensive transverse myelitis combined with tuberculosis meningitis

Abstract Rationale: Central nervous system tuberculosis accounts for 1% of all the tuberculosis (TB) cases, of which tuberculous spondylitis is the most common, followed by scleritis and meningitis. Meningitis associated with transverse myelitis due to tuberculosis is rare but has been reported with severe clinical manifestations, including tuberculous sepsis, symptoms of meningitis and spinal cord injury. Patients concerns: Case 1, a 23-year-old male patient presented with fever, accompanied by quadriplegia and difficulty to urinate. Cultured Koch's Bacillus in liquid environment, Acid-Fast bacilli test, polymerase chain reaction and Xpert MTB/RIF assay for tuberculosis in the cerebrospinal fluid were positive for tuberculosis. Magnetic resonance imaging (MRI) showed heterogeneous signal on T2-weighted (T2W) hyperintensity and fluid-attenuated inversion recovery (FLAIR) images, heterogeneous signal intensity in the spinal cord, unclear medullary border and an increase in D10 - D11 diameter with clear signal in the spinal edges. Case 2, a 20-year-old male patient, presented with fever, severe headache, vomiting and paraplegia. Cultured Koch's Bacillus in liquid environment, testing for acid-fast bacilli test, polymerase chain reaction and Xpert MTB/ RIF tuberculosis in cerebrospinal fluid and sputum was positive for tuberculosis. The MRI displayed hyperintensities on T2W and FLAIR images, a slight increase in the spinal diameter and unclear, heterogeneous signal along the medullary border. Diagnoses: The first patient was diagnosed as tuberculosis meningitis combined with longitudinally extensive transverse myelitis and the second patient was diagnosed with pulmonary tuberculosis, tuberculous meningitis and longitudinally extensive transverse myelitis. Interventions: The two patients were treated with IIIA regimen, rifampicin, pyrazinamide, streptomycin, ethambutol combined with aggressive phase steroids. Outcomes: Following the anti-tuberculous therapy, the fever and mental status was alleviated in case 1, but improvement in muscle power of the limbs and sphincter function improved only after physical rehabilitation training. Case 2 was started on physical rehabilitation during the anti-tuberculous therapy. Though he tested negative for tuberculosis after the medical therapy, the muscle power of the limb showed only marginal improvement after the rehabilitation. Lessons: Meningitis combined with longitudinally extensive transverse myelitis is often difficult to diagnose early because the patients have altered mental status. If the patient has clinical manifestations of lower limb paralysis or quadriplegic paralysis, it is necessary to have an MRI of the spine to determine co-existing transverse myelitis lesions. Low-dose corticosteroid therapy in patients with meningitis combined with transverse myelitis leads to poor nerve recovery.