Introduction: Electrolyte imbalance is common in central nervous system infections. Arginine vasopressin deficiency (AVP-D), Cerebral Salt Wasting (CSW), and Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH) are important etiologies that can cause opposing extremes of serum sodium, posing diagnostic and therapeutic challenges. We report a rare case of transient central AVP-D followed by CSW secondary to tuberculous meningitis (TBM). Case: An 18-year-old female presented with a 1-month history of fever, reduced responsiveness, and visual hallucinations. Her Glasgow Coma Scale was E4V1M4 with neck stiffness and upper motor neuron signs. Initial investigations revealed severe hyponatremia (119 mmol/L) and communicating hydrocephalus with third ventricle ballooning on brain imaging. Coupled with a positive tuberculosis contact, anti-tuberculous therapy was initiated for probable TBM alongside 3% saline correction prior to insertion of external ventricular drain (EVD). Her condition deteriorated on day 5, requiring intubation for aspiration pneumonia. Repeated imaging showed worsening hydrocephalus, necessitating EVD revision. She subsequently developed polyuria (urine output [UO] 150–300 mLs/hour), with biochemical findings consistent with AVP-D (serum sodium 154 mmol/L; urine osmolality 96 mOsm/kg; urine sodium <20 mmol/L). Intravenous desmopressin 1 mcg was administered, and UO reduced to 30 mLs/hour. However, polyuria recurred on Day 9, accompanied by tachycardia, hypotension, and a rapid decline in serum sodium to 120 mmol/L. Diagnosis of CSW was established (urine sodium 204 mmol/L; urine osmolality 470 mOsm/kg). Oral fludrocortisone was initiated and titrated to 0.4 mg daily to maintain serum sodium >130 mmol/L. Due to persistent hydrocephalus, right ventriculoperitoneal shunt was inserted on Day 22, after which her UO gradually decreased, allowing tapering of fludrocortisone. She remains on fludrocortisone 0.1 mg daily with ongoing rehabilitation. Conclusion TBM can be complicated by SIADH, AVP-D, or CSW. Concurrent AVP-D and CSW have not been reported. This case highlights the dynamic electrolyte disturbances in TBM which may lead to diagnostic confusion and therapeutic error. Early recognition and tailored therapy, alongside definitive management to reduce intracranial pressure, are essential for optimal outcomes.
Hypernatremia ; Hyponatremia ; Tuberculosis, Meningeal

The incidence of tuberculosis (TB) infection in multiple organs outside the lungs is of particular concern. We present the case of a 48-year-old woman with a history of pulmonary TB who had a gradual loss of consciousness in one day, worsening shortness of breath, and a cough with green phlegm two weeks before admission. She had been undergoing five days of TB treatment with the drug-sensitive TB treatment regimen. The genital examination revealed a whitish mass in the paraurethral area, which impaired her urination. Blood gas analysis showed respiratory acidosis, and a chest X-ray suggested pulmonary TB and concurrent community-acquired pneumonia. She was diagnosed with extrapulmonary tuberculosis (EPTB) in the central nervous systems and urogenital sites. To treat her lifethreatening EPTB, she received crystalloid infusions, oxygen supplementation, ampicillin-sulbactam (converted to meropenem the next day), an oral fixed-dose combination antituberculosis therapy, pyridoxine, N-acetylcysteine, ursodeoxycholic acid, Curcuma, bisoprolol, proton pump inhibitor, and antiemetics. Additionally, she was inserted with a urethral catheter and a nasogastric tube to assist her urination and nutritional intake. Our facility was a subdistrict hospital and had a limited capacity for diagnosing and treating EPTB due to a lack of advanced intensive care units, blood and sputum cultures, and laboratory panels. After her two-day hospital admission to ICU for stabilisation, she was referred to a higher-level hospital with more advanced pulmonary treatment overseen by a multidisciplinary team. Our resource limitations highlight the importance of being well-informed about evidencebased primary EPTB management strategies.
Tuberculosis, Central Nervous System

Objective: To investigate the relationship between nutritional risk status and clinical outcome in children with tuberculous meningitis (TBM). Methods: The clinical data (basic information, clinical symptoms and laboratory test results) of 112 patients with TBM, who were admitted to Department of Pediatric Infectious Diseases of West China Second Hospital of Sichuan University,from January 2013 to December 2020 were retrospectively analyzed. The patients were divided into the nutritional risk group and the non-nutritional risk group according to the assessment of the nutritional risk by the STRONGkids Scale. The variables of basic information, clinical symptoms and laboratory test measurements etc. were compared between the two groups by using Student t test, Rank sum test or Chi-square test. Multivariate Logistic regression analysis were used to analyze nutritional risk factors. Results: Among 112 patient with TBM, 55 were males and 57 females. There were 62 cases in the nutritional risk group and 50 cases in the non-nutritional risk group. The proportion of cases with nutritional risk was 55.4% (62/112). Patients in the nutritional risk who lived in rural areas, had symptoms of brain nerve damage, convulsions, emaciation and anorexia, with a diagnosis time of ≥21 days, and the level of cerebrospinal fluid (CSF) protein were all higher than those in the non-nutritional risk group ((50 cases (80.6%) vs. 32 cases (64.0%), 20 cases (32.3%) vs.8 cases (16.0%), 33 cases (53.2%) vs. 15 cases (30.0%), 30 cases (48.4%) vs. 2 cases (4.0%), 59 cases (95.2%) vs. 1 case (2.0%),41 cases (66.1%) vs.18 cases (36.0%), 1 406 (1 079, 2 068) vs. 929 (683, 1 208) mg/L, χ²=3.91, 3.90, 6.10, 26.72, 98.58, 10.08, Z=4.35, all P<0.05). The levels of serum albumin,hemoglobin,lymphocyte count, white blood cell count, and CSF glucose were significantly lower in patients with nutritional risk ((36±5) vs. (41±4) g/L, (110±17) vs. (122±14) g/L, 1.4 (1.0, 2.0)vs. 2.3 (1.6, 3.8)×10⁹/L, 7.8 (6.3, 10.0)×10⁹ vs. 10.0 (8.3, 12.8)×10⁹/L, 1.0 (0.8, 1.6) vs. 2.1 (1.3, 2.5) mmol/L, t=-6.15, -4.22, Z=-4.86, -3.92, -4.16, all P<0.05).Increased levels of serum albumin (OR=0.812, 95%CI:0.705-0.935, P=0.004) and lymphocyte count (OR=0.609, 95%CI:0.383-0.970, P=0.037) may reduce the nutritional risk of children with TBM; while convulsions (OR=3.853, 95%CI:1.116-13.308, P=0.033) and increased level of CSF protein (OR=1.001,95%CI:1.000-1.002, P=0.015) may increase the nutritional risk of children with TBM. Similarly, the rate of complications and drug-induced liver injury was higher in the nutritional risk group (47 cases (75.8%) vs. 15 cases(30.0%), 31 cases (50.0%) vs.8 cases (16.0%), χ²=23.50, 14.10, all P<0.05). Moreover, the length of hospital stay was also longer in the nutritional risk group ((27±13) vs. (18±7) d, t=4.38, P<0.05). Conclusions: Children with TBM have a high incidence of nutritional risk. Convulsive, the level of serum albumin, the level of lymphocyte count and CSF protein may affect the nutritional risk of children with TBM. The nutritional risk group has a high incidence of complications and heavy economic burden.It is necessary to carry out nutritional screening and nutritional support for children with TBM as early as possible.
Female ; Humans ; Leukocyte Count ; Male ; Nutrition Assessment ; Nutritional Status ; Retrospective Studies ; Tuberculosis, Meningeal/diagnosis*

tuberculosis (TB) with tuberculous meningoencephalitis (TM) and human immunodeficiency virus (HIV) co-infection in the intensive phase of treatment.METHODS: Fifty-four patients with TB/TM and HIV co-infection were enrolled for this study. Group 1 comprised of 23 patients treated with E and H intravenously, while rifampicin and pyrazinamide were prescribed orally. Group 2 consisted of 31 patients treated with the first-line anti-TB drugs orally. The concentrations of H and E in blood serum were detected using a chromatographic method.RESULTS: A significant improvement in the clinical symptoms and X-ray signs in patients treated intravenously with H and E was observed and compared to group 2. The sputum Mycobacterium tuberculosis positivity was observed during the second month of the treatment in 25.0% of patients from group 1 and 76.1% of the patients from the control group (p=0.003). In addition, nine patients (39.1%) died up to 6 months when H and E were prescribed intravenously compared with 22 (70.9%) in group 2 (p=0.023).CONCLUSION: In TB/TM with HIV, the intravenous H and E treatment was more effective than oral H and E treatment at 2 months of intensive treatment in sputum conversion as well as in clinical improvement, accompanied by significantly higher mean serum concentrations. In addition, the mortality rate was lower in intravenous H and E treatment compared to oral treatment.]]>
Coinfection ; Ethambutol ; HIV Infections ; HIV ; Humans ; Isoniazid ; Meningoencephalitis ; Methods ; Mortality ; Mycobacterium tuberculosis ; Pyrazinamide ; Rifampin ; Serum ; Sputum ; Tuberculosis ; Tuberculosis, Meningeal ; Tuberculosis, Pulmonary

tuberculosis infection to active tuberculosis (TB). However, the significance of the quantitative IFN-γ response in active TB is rarely known. We assessed the association between IFN-γ response to nil, mitogen, and TB mycobacterial antigens, and the variations from serial IGRA testing in active TB of various primary infection sites.METHODS: In total, 102 active TB patients with serial QuantiFERON-TB Gold In-Tube (QFT-GIT) (Qiagen, Germany) were enrolled. The medical records of patients were reviewed for demographic information, infection sites, tuberculosis treatment, and the quantitative IFN-γ response to nil, mitogen, and TB antigen.RESULTS: Patients included 20, 68, and 14 cases of pulmonary TB, extrapulmonary TB, and multiple TB infection, respectively. The quantitative IFN-γ responses to TB antigens differed significantly according to the infection sites (P=0.0001). The median IFN-γ response was the highest in lymph node infection (10.0 IU/mL) and the lowest in central nervous system (CNS) infection (0.02 IU/mL). Of the total, 86.3% showed concordant results in serial testing. Both 50% of the patients with persistent negative results and 62.5% of patients with CNS TB had an insufficient IFN-γ response to mitogen.CONCLUSIONS: Different IFN-γ responses to TB antigens may indicate variable host immune responses among infection sites in active TB disease. Because a few active TB patients fail to produce an adequate IFN-γ response, a study of cellular mechanisms is needed in such unresponsive patients.]]>
Central Nervous System ; Humans ; Interferons ; Lymph Nodes ; Medical Records ; Mycobacterium tuberculosis ; Tuberculosis

To investigate the effects of ventricular shunt placement in children with post-infective hydrocephalus.
 Methods: A total of 24 cases of post-infectious hydrocephalus, who received ventricular shunt, were enrolled. Age, gender, disease progression, clinical manifestation, laboratory data, treatment, prognosis, complication, and sequela for each patient were retrospectively reviewed.
 Results: Of the 24 cases, 8 had a full recovery, 11 had slight sequela, 2 had severe sequela, 1 was in vegetative state, and 2 died because of bacterial meningitis and tubercular meningitis. Epilepsy, mental impairment, visual and hearing damage were the main sequelae.
 Conclusion: Ventricular shunt is the preferred treatment in children with post-infective hydrocephalus, which shows positive clinical efficacy and can improve the long-term prognosis of such patients.
Child ; Humans ; Hydrocephalus ; Retrospective Studies ; Treatment Outcome ; Tuberculosis, Meningeal ; Ventriculoperitoneal Shunt

BACKGROUND: Miliary tuberculosis (TB) can cause diagnostic confusion for clinicians because its radiological appearance can resemble that of metastatic cancer. CASE REPORT: Here, we describe the case of a 72-yearold woman with miliary TB mimicking brain metastasis from renal cell carcinoma. The patient visited our clinic because of dysarthria and sluggish speech. A metastatic cancer such as renal cell carcinoma or brain tumor was suspected. However, the patient was diagnosed with miliary TB associated with multiple intracranial tuberculomas and a subsequent paradoxical response to anti-TB therapy. CONCLUSION: Clinicians should be aware that miliary TB can mimic metastatic cancer even in older people, especially in TB-endemic regions.
Brain Neoplasms ; Brain ; Carcinoma, Renal Cell ; Dysarthria ; Female ; Humans ; Neoplasm Metastasis ; Tuberculoma, Intracranial ; Tuberculosis, Miliary

Toxoplasma encephalitis is an opportunistic infection that may occur in immunocompromised or advanced HIV (Human Immunodeficiency Virus) patients and lead to serious complications in the CNS. We report a 44-year-old man with toxoplasma encephalitis combined with HIV infection. He was admitted with headache and neck stiffness. Brain computed tomography showed normal findings. Tuberculous meningitis was suspected from CSF and serum tests. However, his symptoms continued to progress, and toxoplasma encephalitis was diagnosed based on brain magnetic resonance imaging and serum tests.
Adult ; Brain ; Encephalitis ; Headache ; HIV Infections ; HIV ; Humans ; Humans ; Magnetic Resonance Imaging ; Neck ; Opportunistic Infections ; Toxoplasma ; Tuberculosis, Meningeal

Miliary tuberculosis is a severe form of tuberculosis resulting from dissemination of Mycobacterium tuberculosis bacilli. Since symptoms appearing in patients due to miliary TB are diverse and atypical, depending on the site of invasion, early diagnosis and treatment are important. A paradoxical response of tuberculosis is a rare phenomenon and it can be a clinical difficulty to treatment especially when involving the central nervous system. We present a case report with a review of related literature about the patient who developed sudden hearing loss due to tuberculosis infection in vestibulocochlear area.
Central Nervous System ; Early Diagnosis ; Hearing Loss, Sensorineural ; Hearing Loss, Sudden ; Humans ; Mycobacterium tuberculosis ; Tuberculosis ; Tuberculosis, Miliary

BACKGROUND AND OBJECTIVES: The suppression head impulse (SHIMP) test has emerged as one of the new vestibular function tests. The SHIMP test is an analysis of anti-compensatory saccadic movements in gazing moving targets as the head moves. In this study, we investigated the accuracy and sensitivity of the test. SUBJECTS AND METHOD: We analyzed the results of SHIMP test (gain, amplitude, and latency) in 24 cases, which included normal, vestibular neuritis, benign paroxysmal positional vertigo (BPPV), Meniere's disease, bilateral vestibular function loss, temporal bone fracture, tuberculosis meningitis and acoustic schwannoma patients. We also carried out a physical exam, audiologic study, video electronystagmography (vENG) and a conventional video head impulse test to evaluate the feasibility of SHIMP test in cases of vesitibulopathy. RESULTS: In patients with vestibulopathy, the analysis of SHIMP test indicated high sensitivity and accuracy, which were supported by accompanying audio-vestibular studies. Patients suspected with BPPV, vestibular neuronitis and Meniere's disease showed low vestibulo ocular reflex (VOR) gain and delayed anticompensatory saccade with smaller and more scattered amplitudes than the control. Patients with bilateral vestibular function loss, temporal bone fracture, tuberculosis meningitis, and acoustic schwannoma showed delayed latency, and small amplitude or few anticompensatory saccades. Finally, changes in the SHIMP test values might be a hint that patients had recovered from vestibular neuronitis and tuberculosis meningitis. CONCLUSION: We found the feasibility of SHIMP test in detecting the pathologic condition of VOR in vestibulopathy patients. We argue that the usefulness of SHIMP test might be extended to evaluating the effectiveness of rehabilitation.
Benign Paroxysmal Positional Vertigo ; Electronystagmography ; Head Impulse Test ; Head ; Humans ; Meniere Disease ; Methods ; Neuroma, Acoustic ; Reflex, Vestibulo-Ocular ; Rehabilitation ; Saccades ; Temporal Bone ; Tuberculosis, Meningeal ; Vestibular Function Tests ; Vestibular Neuronitis