An Uncommon Case of Persistent Papilledema without Hydrocephalus in the Setting of Tuberculous Meningitis

Abstract

Tuberculosis (TB) remains a health problem across the world, with an estimated 10.4 million cases and 1.8 million deaths resulting from the disease per year. The most fatal and disabling form of TB is tuberculous meningitis (TBM), of which approximately more than 100,000 new cases are occurring every year. TBM presents as extra-pulmonary TB, caused by the seeding of the meninges with Mycobacterium tuberculosis bacilli forming subependymal clusters known as rich’s foci. They can entrap within blood vessels as well as restrict Cerebrospinal fluid (CSF) flow, resulting in vasculitis, and hydrocephalus, respectively. These immune responses result in complications and sequelae in persons who recover from TBM. The outcome of TBM varies depending on factors such as the severity of the infection, the timing of diagnosis, and the promptness and effectiveness of treatment. Depending on these factors, the mortality rate can range from 20% to 60%. Delays in diagnosis and treatment can lead to complications such as neurological deficits, hydrocephalus, stroke, and vision problems. Here, we have discussed a case of a TBM patient who presented with constitutional symptoms such as headache, fever, cough, weight loss, and dizziness. During hospitalization, she developed a progressive diminished vision which led to difficulty in walking. Radio-imaging showed leptomeningitis without evidence of ventricular enlargement, CSF examination was consistent with TBM, and fundoscopy showed bilateral papilledema. Based on these findings, she was started on anti-TB therapy (ATT), however, her papilledema was persistent even after 15 days of therapy without any evidence of hydrocephalus, which is a very unusual finding in TBM. Our case outlines the rare presentation of papilledema without hydrocephalous in TBM.