Infect Chemother.  2016 Mar;48(1):41-46. 10.3947/ic.2016.48.1.41.

A Case of Disseminated Multidrug-Resistant Tuberculosis involving the Brain

• Jung EK
• Chang JY
• Lee YP
• Chung MK
• Seo EK
• Koo HS
• Choi HJ

• KMID: 2170516
• DOI: http://doi.org/10.3947/ic.2016.48.1.41

Abstract

We report a case of a 23-year-old female immigrant from China who was diagnosed with multidrug-resistant tuberculosis affecting her lung and brain, resistant to the standard first-line therapeutics and streptomycin. She was treated with prothionamide, moxifloxacin, cycloserine, and kanamycin. However, her headache and brain lesion worsened. After the brain biopsy, the patient was confirmed with intracranial tuberculoma. Linezolid was added to intensify the treatment regimen, and steroid was added for the possibility of paradoxical response. Kanamycin was discontinued 6 months after initiation of the treatment; she was treated for 18 months with susceptible drugs and completely recovered. To our knowledge, this case is the first multidrug-resistant tuberculosis that disseminated to the brain in Korea.

Keyword

Mycobacterium tuberculosis; Tuberculosis, multidrug-resistant; Tuberculosis, central nervous system; Tuberculosis, pulmonary

MeSH Terms

Biopsy
Brain*
China
Cycloserine
Emigrants and Immigrants
Female
Headache
Humans
Kanamycin
Korea
Linezolid
Lung
Mycobacterium tuberculosis
Prothionamide
Streptomycin
Tuberculoma, Intracranial
Tuberculosis, Central Nervous System
Tuberculosis, Multidrug-Resistant*
Tuberculosis, Pulmonary
Young Adult
Cycloserine
Kanamycin
Prothionamide
Streptomycin

Figure

• 

  Figure 1 (A) Chest radiograph on admission. Bilateral ground glass opacity is visible. (B) After 2 months of anti-tuberculosis treatment, chest radiography shows no active lung lesions. (C) After 18 months of anti-tuberculosis treatment. No residual lesion.

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  Figure 2 Computed tomography (CT) of chest at admission, showed diffuse bilateral ground glass opacity in both lungs and a nodular consolidation with pulmonary emphysema in right upper lung.

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  Figure 3 (A) Brain magnetic resonance image (MRI) on hospital day 31 showed brain edema and lesions on subcortical white matter of left frontal lobe and left temporal lobe which high signal intensity on T2-weighted image in the subcortical white matter of left frontal lobe (30×22 mm) and temporal lobe (24×20 mm), on coronal view (left) and transverse view (right). (B) Brain CT on hospital day 91. Ring like enhanced lesion with calcification in left frontal lobe (34×22 mm) and temporal lobe (28×19 mm) with enlargement of primary mass and progression of brain edema. (C) Brain CT After 20 months of anti-tuberculosis treatment, residual low density is in left frontal subcortical white matter without enhancement.

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  Figure 4 Clinical course of patients with disseminated MDR-tuberculosis. MTB, Mycobacterium tuberculosis ; B-MRI, brain MRI; B-CT, brain CT; TB, tuberculosis; PCR, polymerase chain reaction; INH, isoniazid; RFP, rifampin; CXR, chest X ray; IPM, imipenem; LVX, levofloxacin; MXF, moxifloxacin; AMK, amikacin; KAN, kanamycin; EMB, ethambutol; CCS, cycloserine; PTH, prothionamide; DMS, dexamethasone; LZD, linezolid; HD, Hospital day.

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  Figure 5 Hematoxylin and Eosin stain of brain biopsy at frontal lobe subcortical white matter lesion. Chronic granulomatous inflammation is visible in the arrow mark.

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