Vol. 6, Issue 1, Part A (2024)

Tuberculosis, a millennium-old disease continues to be a major threat to mankind. Atypical presentation especially in extrapulmonary tuberculosis (EPTB) poses challenges to clinical and laboratory diagnosis leading to delay in initiation of therapy which adds to the morbidity and mortality of the patient. The clinical course may further be deteriorated by coinfection with other bacterial organisms though the occurrence is rare. Herewith we present a case report of a 48-year-old man a known diabetic and hypertensive who presented with fever, neck pain, and back pain for 1 week. Culture of cerebrospinal fluid (CSF) yielded a pure growth of Staphylococcus aureus which was susceptible to oxacillin. MRI of the brain and spine showed the para- vertebral collection in the cervico-dorsal junction (C7-T1). Histopathological examination (HPE) of the aspirate showed caseating granuloma with Langhans giant cell suggestive of Potts's spine. Blood culture and urine culture yielded Staphylococcus aureus susceptible to oxacillin. The patient was started on intravenous ceftriaxone and vancomycin for Staphylococcal meningitis and sepsis. Cartridge-based nucleic acid amplification test (CBNAAT) for CSF did not yield Mycobacterium tuberculosis. As per Index TB guidelines, the patient was started on Antitubercular therapy with fixed-dose combinations on the basis of histopathology. The patient was treated for diabetes and hypertension. The patient tolerated the therapy well and improved with no complications and hence discharged. The patient is being continued on a fixed drug combination of antitubercular therapy. On follow up the patient showed no signs and symptoms of recurrence or neuro deficits.
This case report emphasizes the varying clinical presentation and the need for high clinical suspicion in the diagnosis of concomitant EPTB and pyogenic meningitis.
Multiple diagnostic approaches and prompt initiation of appropriate antibacterial and antitubercular therapy for a better clinical outcome as in this patient. In patients with an atypical clinical presentation of meningitis, one should consider concomitant infections of TB and pyogenic organisms. Early detection and timely intervention are important to reduce morbidity and mortality. Individual complications associated with pyogenic meningitis and Pott’s spine can lead to catastrophic incident which further increases the fatality rate. Missing either infection causes permanent neurological deficits and septic shock.