Sign-in to Ask A Doctor - 24x7
OR
Sign in with Google
What Causes Confusion And Unsteadiness When Diagnosed With Bacterial Meningitis?
Question: My husband has been ill for 90 days now. Presented to ED with confusion & altered gait/balance. First finding in ED was hyponatremia. Admitted & LP was done with CSF WBC of 843. Told it was bacterial meningitis. A few days later no growth in csf culture. Had the 1st MRI that stated inflammation to left mid temporal of brain. Started on Keppra & continuously declined from there. He became incontinent, unable to stand on his own & started appearing like a stroke patient. A second LP was done which showed WBC of 670. After that LP he suffered a focal seizure and was already hard to arouse. A second MRI is done which showed inflammation of the brain is now to the right side as well with hydrocephalus. He ended up with an EVD and was intubated for a week. He was also started on 4 TB medications with a presumed dx of TB meningitis. Was also started on Avalox, Acyclovir, Vanco, Rocephin & Ampicillin regimen. Repeat MRI showed worsened inflammation of the brain. By that time he was already extubated and awake. MD said TB meds are working because he is better. He continued to stay at the hospital. Again, another MRI was done about 3 weeks later which showed worsening inflammation of the brain. By this time, he had been fully awake most of the time but suffered aphasia & right sided paralysis as well. None of the neurosurgeon want to do a brain biopsy because they said we need to allow the tb meds to work first. He was sent to a nursing home. A month after the last MRI, a repeat is done which showed even worse edema to the brain & even stated cerebellar tonsil herniation. We told of the need to be re admitted to the hospital for eval by neurosurgeon. He eventually had brain biopsy a few days later with evd placement again. Specimens were sent to Univ of XXXXXXX for PCR and XXXXXXX XXXXXXX for pathology. All of the testings came back negative. All cultures previously done came back negative as well, even csf flow cytometry. No AFB culture came back positive - sputum & csf. Their only basis for the presumed dx of tb meningitis are positive gamma interferon & adenosine deaminase. Today I was told no other testings can be done & that all options have been exhausted. We are Kaiser Permanente members & are stuck in it. I requested to get another opinion from outside but was declined 2x. Their reasoning being services are available within Kaiser & that they have the finest physicians. All of them are saying he is a rare case. I said that if that is the case then we need to find a doctor who can figure what is making my husband' s brain to swell. I would greatly appreciate a feedback from you. We need help! Yes, he is awake & breathing on his own. However, he still has very sick brain. He is 52 yrs old with only hx of bowel resection in 1988 due to ulcerative colitis. He is a very fit guy & the life of the partybefore getting sick. Thank you.
Brief Answer:
Viral encephalitis to consider as well.
Detailed Answer:
Hello and thanks for using HCM.
I have read your question and understand your concerns.
Regarding to symptoms and MRI findings, it is not only meningitis, but encephalitis as well, the diagnosis to consider.
It is true that there are patients that resulted negative for tuberculosis and still tubercular meningoencephalitis was the diagnosis in the end.
Another condition to consider is viral encephalitis and several viruses may cause it. (herpesvirus, varicella, rubella, measles).
Serological testing about these possible viral infection are necessary too, if they haven't been performed yet.
The medication that was used covers all three possible microorganism that may cause encephalitis ( TB, viral and bacterial ), so, it is difficult to predict the exact nature of the infection by the treatment response.
Since TB was strongly suspected, evaluation of respiratory tract about pulmonary tuberculosis is necessary also.
In mean time, medical treatment about tuberculosis and viral infection, together with the external ventricular drainage should be continued until the WBC cells of cerebrospinal fluid reach the normal value.
I agree with the treatment and diagnostic steps performed by your husband's Doctors, however, getting a second even a third opinion is the best thing to do.
It is necessary to evaluate in details MRI images and tests, in order to offer you a more detailed answer.
Hope I helped you.
Let me know if I can assist you further.
Kind regards.
Viral encephalitis to consider as well.
Detailed Answer:
Hello and thanks for using HCM.
I have read your question and understand your concerns.
Regarding to symptoms and MRI findings, it is not only meningitis, but encephalitis as well, the diagnosis to consider.
It is true that there are patients that resulted negative for tuberculosis and still tubercular meningoencephalitis was the diagnosis in the end.
Another condition to consider is viral encephalitis and several viruses may cause it. (herpesvirus, varicella, rubella, measles).
Serological testing about these possible viral infection are necessary too, if they haven't been performed yet.
The medication that was used covers all three possible microorganism that may cause encephalitis ( TB, viral and bacterial ), so, it is difficult to predict the exact nature of the infection by the treatment response.
Since TB was strongly suspected, evaluation of respiratory tract about pulmonary tuberculosis is necessary also.
In mean time, medical treatment about tuberculosis and viral infection, together with the external ventricular drainage should be continued until the WBC cells of cerebrospinal fluid reach the normal value.
I agree with the treatment and diagnostic steps performed by your husband's Doctors, however, getting a second even a third opinion is the best thing to do.
It is necessary to evaluate in details MRI images and tests, in order to offer you a more detailed answer.
Hope I helped you.
Let me know if I can assist you further.
Kind regards.
Above answer was peer-reviewed by :
Dr. Veerisetty Shyamkumar
AFB sputum culture x3 all negative. 6 CSF samples were cultured for afb all came back negative. Husband had brain biopsy on 12/16/16. Specimen were sent to University of XXXXXXX to test for viral, bacterial including afb and fungal PCR all came back negative. Pathology specimen from that same brain biopsy was sent to XXXXXXX XXXXXXX & came back negative also for cancer markers & any tissue granulation that would suggest tb meningitis. He had been on tb medications for 2 months when this brain biopsy was done. On the first week of Nov. a talk about biopsy was brought up but neurosurgeons said it is not time because of the risks involved but with the MRI result from 12/11/16, they decided it is time. My question is how can they be sure this is tb meningitis when after 2 months on tb meds his brain inflammation got worse. And yes, the tb meningitis already developed into encephalitis. I attached screen shots of brain MRI on Nov 1, 2016, brain MRI on 12/11/16, the procedure he underwent on 12/16/16. He no longer has EVD. He is now in step down unit.
Somehow it is letting me upload only 1 image. I chose to upload the most recent Brain MRI done on 12/11/16, 5 days before craniotomy to do biopsy was done.
Sorry, now I see that all of them are there. A latest EEG is also attached. For these doctors to say that they have no doubt what my husband has is tb meningitis and there is nothing else they can do but continue tb medications is unacceptable. I need to make sure he is getting the treatment he needs. After 2 months on tb medications & decadron, with his MRI showing more inflammation my gut feeling is telling me that these doctors misdiagnosed him.
Somehow it is letting me upload only 1 image. I chose to upload the most recent Brain MRI done on 12/11/16, 5 days before craniotomy to do biopsy was done.
Sorry, now I see that all of them are there. A latest EEG is also attached. For these doctors to say that they have no doubt what my husband has is tb meningitis and there is nothing else they can do but continue tb medications is unacceptable. I need to make sure he is getting the treatment he needs. After 2 months on tb medications & decadron, with his MRI showing more inflammation my gut feeling is telling me that these doctors misdiagnosed him.
Brief Answer:
Stroke to consider also.
Detailed Answer:
Welcome back and thanks for the additional information.
I examined the reports you uploaded too.
Disease entities that may cause those imaging findings and that clinical picture can be infectious, metabolic, neoplastic, and degenerative etiologies.
Cerebrovascular events ( stroke ) also should be considered in cases that infections are excluded.
Basilar artery tip and bilateral posterior cerebral artery occlusion may result in such imaging findings. ( since brainstem is affected also ).
In such cases, full cardiac work up is necessary.
Fungal infections may cause meningoencephalitis in patients who are immuocompromissed.
Neoplasms mainly include gliooma sand biopsy together with characteristic MRI findings are the key to diagnosis.
So, in conclusion, in my opinion, since neoplasms are excluded after biopsy and any viral, TB, fungal or bacterial infection is not diagnosed with certainty, stroke should be considered also.
Hope this helps.
Kind regards.
Stroke to consider also.
Detailed Answer:
Welcome back and thanks for the additional information.
I examined the reports you uploaded too.
Disease entities that may cause those imaging findings and that clinical picture can be infectious, metabolic, neoplastic, and degenerative etiologies.
Cerebrovascular events ( stroke ) also should be considered in cases that infections are excluded.
Basilar artery tip and bilateral posterior cerebral artery occlusion may result in such imaging findings. ( since brainstem is affected also ).
In such cases, full cardiac work up is necessary.
Fungal infections may cause meningoencephalitis in patients who are immuocompromissed.
Neoplasms mainly include gliooma sand biopsy together with characteristic MRI findings are the key to diagnosis.
So, in conclusion, in my opinion, since neoplasms are excluded after biopsy and any viral, TB, fungal or bacterial infection is not diagnosed with certainty, stroke should be considered also.
Hope this helps.
Kind regards.
Above answer was peer-reviewed by :
Dr. Prasad
He had a stroke because of the inflammation. The information given to us is that the tb infection constricts the vessels in his brain. No blood clot found. Cardiac labs are all good. He has no history of cardiovascular disease, no diabetes. Only hx is ulcerative colitis which is well controlled with Lialda before getting admitted on Oct 2. Based on th info I gave you so far, do you also think what he has is tb meningitis?
Is there any other test his doctors can do or have missed? Infectious diseases were tested from his csf - valley fever, lyme disease, west nile, and many others that I cannot even pronounce. Neurocysticercosis test was also neg. Again his brain sample was tested for viral, bacterial, fungal & afb PCR and all turned out negative. I feel that they misdiagnosed him.
Is there any other test his doctors can do or have missed? Infectious diseases were tested from his csf - valley fever, lyme disease, west nile, and many others that I cannot even pronounce. Neurocysticercosis test was also neg. Again his brain sample was tested for viral, bacterial, fungal & afb PCR and all turned out negative. I feel that they misdiagnosed him.
Brief Answer:
Deep stereotactic biopsy?
Detailed Answer:
Hello again and thanks for being on follow up.
Tubercular meningoencephalitis is a possible explanation because other possibilities are excluded and positive gamma inteferon, adenosine deaminase.
Furthermore tuberculosis may result in vasculitis that may justify stroke.
Improvement after anti tubercular therapy also supports this diagnosis.
I guess syphilis, Creutzfeld-Jakob and HIV tests were performed too, so, it remains no other lab tests that may be indicated.
About what other tests can be done, in my opinion, a new contrast enhanced MRI could be discussed with the aim of evaluating any deep brain enhanced focus ( tuberculoma ), if any of these is evident, stereotactic biopsy should be considered, since the first biopsy was performed on material collected on brain surface and meninges.
Hope I helped you.
Wishing you and your husband good health.
Deep stereotactic biopsy?
Detailed Answer:
Hello again and thanks for being on follow up.
Tubercular meningoencephalitis is a possible explanation because other possibilities are excluded and positive gamma inteferon, adenosine deaminase.
Furthermore tuberculosis may result in vasculitis that may justify stroke.
Improvement after anti tubercular therapy also supports this diagnosis.
I guess syphilis, Creutzfeld-Jakob and HIV tests were performed too, so, it remains no other lab tests that may be indicated.
About what other tests can be done, in my opinion, a new contrast enhanced MRI could be discussed with the aim of evaluating any deep brain enhanced focus ( tuberculoma ), if any of these is evident, stereotactic biopsy should be considered, since the first biopsy was performed on material collected on brain surface and meninges.
Hope I helped you.
Wishing you and your husband good health.
Above answer was peer-reviewed by :
Dr. Arnab Banerjee
Answered by
Get personalised answers from verified doctor in minutes across 80+ specialties
