【Philips 1 case per day】Intracranial tuberculosis is misdiagnosed as a case of intracranial metastatic malignancy

1 Case data

Female, 25 years old

Sudden speech inability during intravenous infusion during 40 days of admission, weakness of the right limb with movement disorders, referral to a municipal hospital, check cerebrospinal fluid routine, biochemical examination without obvious abnormalities, diagnosis: (1) cerebral infarction; (2) Intracranial infection? (3) Multiple small nodular shadows of the lungs, metastases? (4) Intestinal tumors? Anti-platelet aggregation, anti-infection and other treatments were given, and the symptoms did not improve, and the weakness of the right limb gradually worsened

Half a month before admission, he visited a hospital in Xiamen, and chest CT showed multiple metastases

Positron emission computed tomography (PET)-CT shows cancer of the right half of the colon with multiple lymph node metastasis in the abdominal cavity and retroperitoneum, metastasis of both lungs, and brain metastasis

Diagnosis: right hemicolon cancer with both lung metastases, brain metastases

Fig.

Physical examination: sluggish expression, unclear speech, stiff neck; Gross breath sounds in both lungs; Right limb strength grade I, elevated muscle tone, positive for Creche sign, positive for right Babinski sign

Diagnosis: (1) tuberculous meningitis; (2) Tuberculosis; (3) Intestinal tuberculosis

High-dose isoniazid, rifamycin, streptomycin, pyrazinamide, and lumbar puncture intrathecal injection of isoniazid antituberculosis are given, supplemented by intracranial pressure reduction

Symptoms improved after 1 week, without low-grade fever or night sweats

After 2 months, the cerebrospinal fluid returned to normal, and chest CT examination showed obvious absorption of the lesion, see Figure 2

Fig.

2 Discussion

Intracranial tuberculosis is a polymorphic lesion formed by the hematological spread of Tuberculosis bacteria into the skull, with serious complications and high case fatality rate, which is one

2.

The clinical manifestations of intracranial tuberculosis lack characteristics, are related to the site of lesion involvement, and are mainly manifested as headache, dizziness, vomiting, convulsions, impaired consciousness, hemiplegia, etc.

2.

(1) The clinical manifestations are non-specific and similar
to the corresponding tumor manifestations.
In this case, intestinal tuberculosis is manifested by right lower abdominal pain and constipation, and tuberculous meningitis is manifested by right limb hemiplegia and slurred speech, similar to
intracranial malignancy.
(2) Too dependent on PET-CT test results
.
(3) The systemic toxicity symptoms of tuberculosis in this case are not obvious, and only show low-grade fever, so clinicians ignore the diagnosis
of tuberculosis.

2.
3 Measures to prevent mistreatment

(1) Increase vigilance, carefully and carefully ask the patient's medical history and meticulous physical examination, for patients with a history of tuberculosis should think of the possibility of extrapulmonary tuberculosis, and do not easily exclude extrapulmonary tuberculosis for those without a history of tuberculosis
.
(2) Dna testing
of Mycobacterium tuberculosis should be improved in a timely manner.
This technology is fast and accurate, high specificity, low false negative rate, short time consumption, shortening the detection time of extrapulmonary tuberculosis diagnosis, and providing effective support
for early diagnosis and treatment.
(3) For those who are difficult to diagnose, especially those who have difficulty distinguishing from the corresponding tumors, they should take the living tissue for pathological examination
in time.
(4) When intracranial tuberculosis is suspected, lumbar puncture cerebrospinal fluid can be repeatedly performed, which is extremely important
for its diagnosis.
(5) Those who cannot confirm the diagnosis through existing methods and have a high degree of suspicion of intracranial tuberculosis can standardize diagnostic anti-tuberculosis treatment and follow up regularly to correctly evaluate the effect of
anti-tuberculosis treatment.

In short, for intracranial tuberculosis, clinicians should carefully ask the patient's medical history and meticulous physical examination, and promptly perform cerebrospinal fluid examination and Mycobacterium tuberculosis DNA testing to avoid misdiagnosis
.