Permanent visual loss despite appropriate therapy in tuberculous meningitis.

To the Editor: Tuberculous meningitis (TBM) is one of the most serious forms of tuberculous disorders with considerable complications and mortality. (1) Ocular complications may result from optochiasmatic arachnoiditis, hydrocephalus, development of tuberculoma which presses on optic pathways, or anti-TB therapy. (2) We herein report a case of TBM causing sudden onset and rapidly progressive visual loss despite appropriate anti-TB therapy.

An 18-year-old female presented with headache, vomiting, and seizures for 10 days. She was initially treated symptomatically, and cranial CT remained negative. She was conscious but lethargic, and temperature was 38.7[degrees]C. Nuchal rigidity, Kernig and Brudzinski signs were positive. The analysis of cerebrospinal fluid (CSF) revealed increased pressure of 300 mm [H.sub.2]O (N: 50-180 mm [H.sub.2]O), clear appearance, WBC count 180/[mm.sup.3] (75% lymphocytes) and erythrocytes 660/[mm.sup.3], (N: 0-5 mononuclear cells/[mm.sup.3]), glucose level 33 mg/dL (N: 40-70 mg/dL), and protein 229 mg/dL (N: 15-45 mg/dL). Chest x-ray was normal. No bacteria were seen on the CSF smear. On the second day, ptosis and restriction in lateral eye movements on the right eye developed. CSF culture yielded no pathogens. Meningeal contrast enhancements were detected on MRI. Tuberculin skin test was positive (18 mm). Anti-HIV antibodies remained negative. Anti-TB therapy and prednisolone were started. On the third day, complete visual loss occurred. Cranial CT showed obstructed fissures and sulci and dilated ventricles. Cranial MRI showed obvious focal contrast enhancement in cerebral and cerebellar tissues, tension of the infundibular stalk and inferior shift at the optic chiasm. Repeated ophthalmic examination revealed bilateral optic atrophy with left macular choroiditis.

Polymerase chain reaction against Mycobacterium tuberculosis was positive in CSF and it cultured M tuberculosis. She completed 12 months of anti-TB treatment; however, total visual loss persisted. A control magnetic resonance study revealed dilation of the ventricles, bilateral thinning of the optic nerves, and prominent atrophy on the right side of the optic chiasm (Fig.). The last visit was performed 4 months after the treatment; total visual loss associated with bilateral optic atrophy with left macular choroiditis persisted.

[FIGURE OMITTED]

TB affects the entire visual system, from the eyelids to the optic nerve. (3) Ocular complications may develop during the course of TBM, resulting from optochiasmatic arachnoiditis, hydrocephalus, uveitis, development of tuberculoma which presses on optic pathways, or anti-TB therapy. (2) Tuberculomas may involve the optochiasmatic region and may cause visual dysfunction.

Visual function may be impaired due to optochiasmatic arachnoiditis, where tuberculoma and lesion with mass effect may not be detected on MRI. (1,2) Surgery is not expected to improve the function. Visual loss in our case is due to optochiasmatic arachnoiditis which developed secondary to TBM. Tuberculoma around the chiasma could not be found. Since neuro-ophthalmic complications began just before the therapy and rapidly progressed, any contribution of anti-TB therapy to visual impairment is not likely.

In conclusion, total visual loss may occur in TBM. Anti-TB treatment should be vigorous and complete, to minimize a poor outcome. Despite increased awareness and improved diagnostic modalities, morbidity and mortality remain considerable in tuberculous meningitis.

Mustafa Sunbul, MD

Hakan Leblebicioglu, MD

Derya Turan, MD

Saban Esen, MD

Department of Clinical Microbiology and Infectious Diseases

Arif Onder, MD

Department of Neurosurgery

Ondokuz Mayis University Medical School

Samsun, Turkey

Resat Ozaras, MD

Recep Ozturk, MD

Department of Clinical Microbiology and Infectious Diseases

Istanbul University Cerrahpasa Medical School

Istanbul, Turkey

References

1. Henry M, Holzman RS. Tuberculosis of the brain, meninges, and spinal cord. In: Rom WN, Garay SM (eds). Tuberculosis, 2nd ed. Philadelphia, Lippincott Williams & Wilkins, 2004, pp 445-464.

2. Kadioglu HH, Gundogdu C, Deniz O, et al. Optochiasmatic tuberculoma-case report and review. Zentralbl Neurochir 1996;57:30-36.

3. Friedberg DN, Lorenzo-Latkany M. Ocular complications. In: Rom WN, Garay SM (eds). Tuberculosis, 2nd ed. Philadelphia, Lippincott Williams & Wilkins, 2004, pp 465-476.

It is good to have an end to journey toward; but it is the journey that
matters, in the end.
--Ursula K. LeGuin