Right Cerebellar Tuberculosis with Cranial Nerve Palsy in Pulmonary Tuberculosis Patient

Article history: Introduction: Tuberculosis (TB) is a major public health issue. The most devastating Received 06 April 2020 clinical manifestations of TB is Central nervous system (CNS) TB. CNS TB is found Received in revised form 11 May approximately in 1% of all patients with active TB, and cerebellar TB is rarely reported. 2021 CNS TB can present as meningitis, arachnoiditis, tuberculomas, or the uncommon Accepted 26 May 2021 forms of tuberculous subdural empyema and brain abscess. Available online 31 May 2021 Case: A 23-year-old patient was reported in October 2018 with signs and symptoms of


INTRODUCTION
In 2017, it was estimated that 10 million people developed TB, which consisted of 1 million children, 3.2 million women, and 5.8 million men. 1 TB with CNS involvement accounts for approximately 1% of all TB diseases, [2][3][4] and the rare form of CNS TB is brain abscess. 5,6 CNS TB patients who have no Human Immunodeficiency Virus (HIV) infection occurs in only 4 to 8% of patients. 7 There are 3 clinical-pathological forms of CNS TB, tuberculomas, meningoencephalitis, and abscesses. 8 Tuberculous brain abscess (TBA) is uncommon and cerebellar tuberculosis is a very rare form of CNS TB. 9,10 The high morbidity and mortality characteristics of CNS TB are very important to note, thus the prompt diagnosis and therapy should be done. It is also important to prevent the severe neurological sequelae, even in patients who are adequately treated. 11,12 The signs and symptoms, brain imaging, and laboratory findings of CNS TB are nonspecific, but the initial diagnosis is based on it, and the definitive diagnosis is made by bacteriological methods. 10,12,13 ATD treatment is given immediately because of high morbidity and mortality rate in CNS TB. 14 Although the effective ATD therapy has been performed, adverse results usually occur in patients with CNS TB, such as severe neurological sequelae and death. For the prevention of these adverse results, corticosteroids have been used as an adjunctive in the medication. 2,13 For the end of therapy in patients with CNS TB, there are no established criteria recently. The response of the medication frequently must be based on clinical and brain imaging findings. For patients with CNS TB, bacteriological evaluation is limited because of the difficulty in getting specimens. 15

CNS
TB can be noticed in both immunocompetent and immunocompromised patients.
We reported an immunocompetent patient, a young adult, who had contact with TB patient (his father), who was diagnosed with right cerebellum TB and PTB.

CASE
A 23-year-old patient was reported in October 2018 with signs and symptoms of 2-month history of vertigo, headache, vomiting, weakness, fever, blurred vision, lingual palsy, dysmetria, and decrease of consciousness. The patient had a few months of history of cough, contact with a TB patient, his father, and loss of body weight. On admission, the patient had pyrexia (38.5 0 C) and Glasgow coma score of 13. Neurological examination revealed a decrease of consciousness and direction-changing positional nystagmus. The general examination also showed a decrease of visus, in 1/3 lower of right hemithorax was dullness in percussion, and a decrease of vesicular breath sound. The result of AFB-stained sputum was 1+. The chest X-ray ( Figure 1) revealed the fibro infiltrates process in both hemithoraxes, homogenous opacity at the right lower hemithorax, and the costophrenic angle blunting at the right hemithorax. The head CT-scan ( Figure 2) without contrast revealed a cystic lesion in the right cerebellar hemisphere and with contrast revealed a ring-enhancing mass in the right cerebellar hemisphere. Figure 1. Chest X-ray revealed the fibro infiltrates process in both hemithoraxes, homogenous opacity at the right lower hemithorax, and the costophrenic angle blunting at the right hemithorax  The patient was diagnosed with right cerebellar TB and PTB. Surgery was preferred as medical treatment, which was reserved for diagnostic and therapy of complications, but the patient's family disagreed and denied the action. ATD treatment, including rifampicin, isoniazid, pyrazinamide, ethambutol, and streptomycin, were given.
Corticosteroid (dexamethasone) was also given as indicated.
The evaluation was performed after the patient underwent the ATD treatment for 12 months. In the evaluation, the patient had no complaints and could do his daily activities well. The evaluation of brain MRimaging ( Figure 6) did not show a ring-enhancing mass in the right cerebellar hemisphere, but in the FLAIR sequence revealed the perifocal edema could be caused

DISCUSSION
TB is a fundamental public health problem in developing countries. The most usual clinical presentation of active TB is pulmonary TB (PTB), but TB can manifest in any tissue of the human body including CNS. The involvement of CNS in TB is rare and is associated with high mortality and morbidity rates, even inadequately treatment. 11,12 CNS TB can occur in an immunocompromised patient with malnutrition, whether a child or young adult. In TB with HIV-positive patients, CNS involvement is five times more often than HIV-negative patients. 16  Culture of Mycobacterium TB organisms from a specimen obtained from the patient is a gold standard for definitive diagnosis of TB, 15 but the easily accessible tools for diagnostic suspected patient of PTB is AFBstained sputum. 18,19 When the patients are suspected of suffering an extra-pulmonary TB (EPTB), every test should be made to obtain tissue/relevant body fluid for diagnostic testing. 20 The sensitivity of diagnostic tests is low, it can be caused by the difficulty in obtaining the specimens. 15 Prompt diagnosis of tuberculous etiology is significant for clinical outcome and a history of recent TB contact is also important. 16 Cerebrospinal fluid (CSF) examination (e.g., CSF AFB staining, CSF culture, CSF analysis) is important for a diagnostic test of TBM. 13 In cases of TBA and tuberculomas, the histological examination is a gold standard for diagnostic, and about 60% of tissue specimens show AFB in smear and culture. 16 The signs and symptoms, brain imaging, and laboratory findings of CNS TB are nonspecific, but the initial diagnosis is based on it, and the definitive diagnosis is made by bacteriological methods. 10,12,13 The lumbar puncture (LP) was not performed in this case because of the increased intracranial pressure (ICP) as a contraindication for LP. Surgery was preferred as medical treatment, which was reserved for diagnostic and therapy of complications. Hydrocephalus with raised ICP requires CSF diversion by ventriculoperitoneal shunt insertion. The surgery was not performed because the patient's family disagreed and denied the action.
Early treatment is important to avoid severe neurological sequelae. ATD treatment is given immediately because of high morbidity and mortality rate in CNS TB. 14 Although the effective ATD therapy has been performed, adverse results usually occur in patients with CNS TB, such as severe neurological sequelae and death. For the prevention of these adverse results, corticosteroids have been used as an adjunctive in the medication. 2,13 In this case, ATD and dexamethasone were given early and observation for the decrease of consciousness was performed continuously. In several days, the patient's condition was getting better. In this case, the patient was given the ATD treatment for 12 months consisting of intensive phase for 2 months (rifampicin, isoniazid, pyrazinamide, ethambutol, and injection of streptomycin) and continuous phase for 10 months in the intermittent dose (isoniazid and rifampicin).
For the end of therapy in patients with CNS TB, there are no established criteria recently. The response of the medication frequently must be based on clinical and brain imaging findings. For patients with CNS TB, bacteriological evaluation is limited because of the difficulty in getting specimens. 15 In this case, the evaluation of the treatment was based on clinical and brain imaging findings. The patient had no complaints and could do his daily activities well.

A B
The evaluation of brain MRI did not show a ringenhancing mass in the right cerebellar hemisphere and in the FLAIR sequence revealed the perifocal edema could be caused by post-infection.

CONCLUSION
The high morbidity and mortality characteristics of CNS TB are very important to note, thus the prompt diagnosis and therapy should be done. The specific therapy of ATD combined with surgery seems to provide a good result. The clinical and radiological findings were used as the evaluation of the medication.