Letters

Tuberculous Meningitis Associated with Diabetic Ketoacidosis

Acute infection can precipitate diabetic ketoacidosis (DKA) in patients with diabetes mellitus (DM)(1). However, we have not come across any case reported where tuberculous meningitis (TBM) was associated with DKA. We report a case where TBM had possibly precipitated DKA.

An 8-year-old girl presented with pain abdomen of 8 days, high grade fever and headache of 4 days, altered behavior of 2 days and difficulty in breathing on the day of presentation. Although, history revealed in-creased amount of urine and increased thirst for the previous 2 weeks, there was no history of polyphagia or DM. In fact, for the preceding 8 days the child had anorexia.

The child was febrile, irritable, disoriented and severely dehydrated. Pulse rate of 124/minute, respiratory rate of 44/ minute with increased depth of respiration, blood pressure of 106/70 mmHg were recorded on admission. Abdomen showed palpable liver (span 7 cm) and spleen (2 cm below left costal margin). Neurological examination was unremarkable except for irritability and disorientation. Ophthalmoscopic examination was normal.

She had normal Hb, total and differential leukocyte count, ESR, blood urea and serum creatinine. Random plasma glucose was 464.4 mg/dl. Urine showed sugar >2%, albumin +, presence of ketones and a normal microscopic picture. Widal and tuberculin tests were negative. Chest X-ray was normal.

A diagnosis of type-1 DM with DKA with occult infection was made. Treatment was started with intravenous fluids, antibiotics, insulin infusion, and antipyretics. Plasma glucose was monitored regularly. On the following 2 days the child's condition improved rapidly but high grade fever persisted. She was oriented, cooperative but somewhat drowsy and complained of headache. Respiration was of normal pattern. On the fourth day she slept for most of the time. In the night on the same day she had a lower motor neuron facial palsy on the left side but was conscious and oriented. There were no signs of meningeal irritation. A "Bell's palsy" was suspected. Next morning she developed a hemiplegia on the right side and minimal neck stiffness.

The CT scan of brain displayed an infarct in the region of left basal ganglia. CSF examination showed 80 leukocytes/cubic mm (95% lymphocytes), glucose 27 mg/dl, proteins 147 mg/dl and a `cob-web' on standing. CSF staining demonstrated acid-fast bacilli, implying a diagnosis of TBM.

The child was put on antituberculosis treatment (rifampicin, isoniazid, pyrazinamide and streptomycin) and prednisolone (with appropriate increase in insulin dosage). The patient improved gradually and became afebrile though the hemiplegia and the facial palsy persisted during her hospital stay of 21 days.

The diagnosis of TBM can be difficult early in its course(2) with nonspecific symptoms in stage I (fever, headache, irritability, drowsiness, etc.) most of which are also common in DKA. Therefore associated DKA could easily mask stage I TBM, as in our patient. However, presence of these symptoms in our case for only 4 days prior to admission and history of lack of appetite of 8 days duration suggests, on retrospective analysis, that the process of activation of TBM started within a short period before admission. It is evident from the presence of polyuria and polydypsia preceding the above symptoms that DM was present even before activation of the TBM occurred. It is also likely that presence of DM might have reactivated the tuberculous process(3,4), leading to TBM.

In situations with high prevalence of tuberculosis, our report suggest that when central nervous system symptoms are not completely abated after the initial treatment of DKA, one must rule out TBM because once TBM enters stage II or stage III, morbidity and mortality are higher.

Devaraj V. Raichur,
Rajan V. Deshpande,
Chandragowda D.K.,
Vithal Clinic and Children's Hospital, Dharwad 580 008, India.

References

1. Ennis ED, Kreisberg RA. Diabetic ketoacidosis and the hyperglycemic hyperosmolar syndrome. In: Diabetes Mellitus. A Fundamental and Clinical Text. Eds. Le Roith D, Taylor SI, Olefsky JM. Philadelphia, Lippincott-Raven Publishers, 1996; pp 276-286.

2. Sperling MA. Diabetes Mellitus. In: Nelson Textbook of Pediatrics, 15th edn. Eds. Nelson WE, Behrman RE, Kliegman RM, Arvin AM. Philadelphia, W.B. Saunders Co, 1996; pp 1646-1666.

3. Pinching AJ. Acquired immunodeficiency and the acquired immunodeficiency syndrome (AIDS). In: Oxford Textbook of Pathology. Eds. McGee J O'D, Issacson PG, Wright NA. Oxford, Oxford University Press, 1992; pp 285-293.

4. Zack MB, Fulkerson LL, Stein E. Glucose intolerance in pulmonary tuberculosis. Am Rev Resp Dis 1973; 108: 1164-1169.