Anil Gurtoo

Meenakshi wadhwani

Rajiv Garg

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GLOBAL JOURNAL OF MEDICINE AND PUBLIC HEALTH        1  www.gjmedph.org Vol. 2, No.  2013                                                                                                                                                                               ISSN#- 2277-9604  Bilateral cortical blindness secondary to tuberculous meningitis in a young Indian female  Meenakshi wadhwani1*, Rajiv Garg2, Anil Gurtoo3                                We  are  reporting  this  case  to  highlight  the importance  of  prompt  treatment  and  diagnosis  in case of tuberculous meningitis  A 30 year old female presented with the complaint of sudden painless total loss of vision for the past five days. This diminution of vision was associated with headache and fever (99°F) for  the  past  one  month.  There  was  no  history  of seizure, painful ocular movement or ocular trauma. Patient was taken to medical practitioner where she was  started  on  intravenous  medication  nature  not known and was referred to our hospital. There was a past history of pulmonary tuberculosis 4 year back for which  she  took antitubercular  treatment  for  1 year (Isoniazid, Rifampicin, Pyrizinamide, Ethambutol and Streptomycin)  was  declared  cured.  Patient  looked emaciated, thin built and had altered sensorium.On systemic  examination,  all  the  systems  were  within normal  limits  except  for  her  neurological  system which  revealed  a  positive  Babinski  sign  and  neck rigidity.  On  ocular  examination  her  visual  acuity  in both the eyes was no perception of light. Pupils were normal  in  size,  direct  and  consensual  pupillary reactions  were  normal  in  both  the  eyes,  ocular movements were full in both the eyes. In posterior segment  examination,  optic  nerve  and  rest  of  the fundus  was  within  normal  limits.  Rest  of  the examination  of  anterior  and  posterior  segments  of both the eyes were within normal limits.  Intraocular pressure was within normal limit1. CT scan of head showed  hydrocephalus  with  infarct  in  both  the occipital  lobes  (Fig.  1A,B).  She  was  admitted  on emergency basis in the ophthalmology ward with a provisional  diagnosis of  hydrocephalus secondary  to tuberculous meningitis  with cortical blindness  and was  started  on  I/V mannitol  and  oral acetazolamide  and injection dexamethasone 1mg/kg.     Her  routine  hematological  and  biochemical  tests done  on  the  day  of  admission  was  within  normal limits.  Her  chest  x  ray  did  not  show  any  active tubercular lesion. Her general condition deteriorated on second day, she had three episodes of vomiting and  stopped  responding  to  verbal  commands  and was shifted to Neurology ward where she was started on  5  drug  (HRZES)  antitubercular  treatment  ,  I/V vancomycin, I/V acyclovir, 5% dextrose drip. Lumbar puncture was done and CSF studies showed presence of coagulum, ADA 12.20, total proteins 90.10 mg/dl, globulin not increased, glucose 33, chloride 126, 0.24 x109 cells with predominant lymphocytes and no AFB. Her HIV was non reactive. Despite of all the above treatment her condition deteriorated and she died on fifth day.  GJMEDPH 2013; Vol. 2, issue 3 1 Pool officer RPC, AIIMS New Delhi ,India  2  Prof.Ophthalmology L.H.M.C.  New Delhi, India  3 Prof.and  HOD Medicine L.H.M.C.  New Delhi, India  *Corresponding Author Pool officer RPC, AIIMS New Delhi ,India  mkgang08@gmail.com  Conflict of Interest—none   Funding—none         2  www.gjmedph.org Vol. 2, No.  2013                                                                                                                                                                               ISSN#- 2277-9604  Case Reports Tuberculous  meningitis  is  particularly  a  distressing disease. Meningitis can result from direct meningeal invasion during a tuberculous bacillemia either at the time of initial infection or at the time of breakdown of an  old  pulmonary  infection.  It  can  also  result  from breakdown  of  an  old  parameningeal  focus  with rupture  into  the  subarachnoid  space,  leading  to diffuse meningitis or localized arteritis. Small or large vessel  arteritis  is  the  principal  feature  in  the presentation  of  tuberculous  meningitis.  Cortical blindness could possibly be due to arteritis (posterior inferior  cerebellar  arteries)  leading  to  infarction  of occipital lobe4,5. In view of her past history, present clinical  examination,  CSF  findings  and  CT  scan  a provisional  dianosis  of  tubercular  meningitis  was made.  Cerebral  vasculitis  and  infarction  may  have resulted due to relapse of her disease. It is possible that  cerebral  arteritis  and  ischemia  leading  to occipital  lobe  infarct  resulted  in  sudden  onset  of cortical blindness1-3.   Even inspite of prompt and rapid treatment patient died on the fifth day. This indicates the bad prognosis in  a  patient  of  cortical  blindness  with  tubercular meningitis.  The  cause  of  death  could  be  diffuse arteritis therefore leading to ischemia and infarction of  occipital  lobe.  In  meningitis,  the  scan  may  be normal  but  can  also  show  diffuse  edema  or obstructive  hydrocephalus.  The  treatment  strategy for tuberculous meningitis and hydrocephalus should be aggressive, anti-tuberculous drugs and wherever necessary intravenous steroids should be started5.        REFERENCES           1.  Garg  R.K. Tuberculosis  of  the  central  nervous system. Postgrad Med J. Mar 1999;75(881):133-40. 2.  Monga  P.K,  Dhaliwal  U.    Paradoxical  reaction  in tubercular  meningitis  resulting  in  involvement  of optic radiation.  Indian J Ophthalmol:2009;57:139-41. 3.  Semlali S, El Kharras A, Mahi M, Hsaini Y, Benameur M,  Aziz  N,  et  al. Imaging  features  of  CNS tuberculosis. J Radiol. Feb 2008;89(2):209-20. 4.  Rock R.B, Olin M, Baker C.A, Molitor T.W, Peterson P.K. Central  nervous  system  tuberculosis: pathogenesis  and  clinical  aspects. Clin  Microbiol Figure 1(A) Axial section showing mid dilatation of both the lateral ventricles suggestive of hydrocephalus (B) Coronal section showing hypodense areas (arrows) in both the occipital lobes suggestive of infarct in both the grey and white matter       3  www.gjmedph.org Vol. 2, No.  2013                                                                                                                                                                               ISSN#- 2277-9604  Case Reports Rev. Apr 2008;21(2):243-61 5.  Goel A. Tuberculous meningitis and hydrocephalus. Neurol India. 2004;52:155.                 

Bilateral cortical blindness secondary to tuberculous meningitis in a young Indian female

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