By Tedler D. Depaynos, MD

definite.“
In layman’s term, TB (Tuberculosis) Meningitis is actually infection of the brain because the meninges covers the brain. It is usually an extension of TB infection from other parts of the body mostly from the lungs. So that in 70% of cases, patients with this disease has pulmonary TB which can be confirmed by chest x-ray.
From our old textbooks, this is usually found in young individuals especially those in the low income group.
Early diagnosis of TB Meningitis is in general difficult because the early manifestations are vague and non-specific. In advanced cases, when other parts of the brain are affected producing neurological defects, involvement of the brain is then obvious. The following as related by a young colleague is an example of a challenging case.
The 54 years old male patient has been having high fever for the past 3 days. Thinking that it is just a Systemic Viral Disease or “trankaso” he just stayed at home and took “paracetamol”. Because of the persistent headache and the fever appeared to be constantly high, he finally sought hospital admission.
He had experienced “trankaso” from time to time and he knows that it usually disappears after 3 to 5 days. Since it is just a viral disease he never took antibiotics as advised by his family MD. But this time it seems to be different especially with the persistent headache which is making him very uncomfortable.
His initial blood examinations implied a viral infection so that Typhoid Fever and Dengue were routinely considered and tested. They were however, negative. Although he denies any history of coughing, his chest x-ray, revealed “basal pneumonia”. Because of this, he was referred to a pulmonologist who gave strong antibiotics because it must be causing the high fever and consequently the severe headache.
After 6 days despite the disappearance of the lung infection as shown by a repeat x-ray, the fever was persistent and the headache became more severe. Thinking of a cranial lesion, the pulmonologist referred the patient to a neurologist who suggested a CT Scan of the head. The CT Scan result was insignificant so that probably the severe headache was due to the unremitting high fever.
As to the cause of the fever, it was still a puzzle. An Infectious Disease Specialist was then consulted and a further work-up was done. Still the cause of the fever was still a puzzle.
Meanwhile, the patient started to be having “melena” or passing out stools with digested blood or “dinuguan”-like stools. Although bleeding may be due to the “stress” the patient was experiencing, a Gastro-Enterologist was called who suggested a Gastro-Endoscopy to confirm the diagnosis. Actually, this is seen in some patients especially those with a history of peptic ulcer. Staying in the hospital itself is already stressful and what more if you are sick!
Meanwhile, blood was transfused to correct the resulting anemia.
Because of the persistent headache, the neurologist was again called who did a spinal tap. Although the lab results of the taken spinal fluid were negative for TB bacteria, the neurologist interpreted the results as due to TB Meningitis. He was definite that the patient was suffering from TB Meningitis! Hence anti-TB medications were started.
With the anti-TB drugs, the headache and fever eventually disappeared. The origin of the TB infection, however, was not yet definite.
With persistent “dinuguan”-like stools, the Gastro-Endoscopy was pushed thru. Although, erosions in the stomach (gastritis) and in the duodenum (doudenitis) and ulcers were visualized, bleeding coming from these were negative. The bleeding must then be coming from the lower intestine or upper colon. Bleeding from the lower colon would be fresh since the blood would have no time to be digested.
A Colonoscopy was then done which revealed a bleeding mass at the junction of the ileum and ceacum. On biopsy, it was due to TB, hence, it must be the primary site of the tuberculous infection.
According to the young colleague, all the attending MDs including him were relieved of their stress when the patient was finally discharged walking. They all nearly also passed out ”melena”. **