title: Severe hyponatremia and MRI point to diagnosis of tuberculous meningitis in the Southwest USA.
abstract: A 21-year-old woman presented to the hospital with 3 days of headache, fever, mood disturbance and nausea. She had recently emigrated from India, and was noted to have a positive screening purified protein derivative tuberculosis skin test with normal chest x-ray. Meningeal signs were noted prompting lumbar puncture and initiation of presumptive treatment for bacterial meningitis. While tuberculous meningitis (TM) was entertained at admission, diagnosis was clouded by the rapid onset of symptoms and recent major psychosocial stressors. She developed severe hyponatremia. Brain MRI revealed tuberculomas, and she was started on treatment for TM, a diagnosis confirmed by culture. On review, several lessons were learned: (1) globalisation of society makes uncommon diagnoses present in unlikely locations, (2) hyponatremia is a common complication of TM, (3) MRI can aid in diagnosis of TM and (4) cognitive and mood changes can be prodromal symptoms of TM.
authors.affiliation: Department of Family Medicine, Southern New Mexico Family Medicine Residency Program, Las Cruces, New Mexico, USA. stephanie.benson@lpnt.net
authors.forename: Stephanie Michelle
authors.initials: SM
authors.lastname: Benson
authors.forename: Rashmi
authors.initials: R
authors.lastname: Narasimhamurthy
mesh_terms: D000328:Adult; D000995:Antitubercular Agents / Q000008:administration & dosage / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D004977:Ethambutol / Q000008:administration & dosage / Q000627:therapeutic use; D005260:Female; D006801:Humans; D007010:Hyponatremia / Q000150:complications* / Q000628:therapy; D007538:Isoniazid / Q000008:administration & dosage / Q000627:therapeutic use; D008279:Magnetic Resonance Imaging / Q000379:methods*; D011718:Pyrazinamide / Q000008:administration & dosage / Q000627:therapeutic use; D012293:Rifampin / Q000008:administration & dosage / Q000627:therapeutic use; D015206:Southwestern United States; D014390:Tuberculosis, Meningeal / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy; D055815:Young Adult
chemical_list: D000995:Antitubercular Agents; D011718:Pyrazinamide; D004977:Ethambutol; D007538:Isoniazid; D012293:Rifampin