Background Tuberculous pachymeningitis is a rare form of extrapulmonary tuberculosis usually suspected from the detection of thickening of the dura in contrast-enhanced magnetic resonance imaging. Progressive nature of the disease can lead to chronic headache with focal neurological signs due to compression from the thickened dura. Case Report We report a 40-year-old female who presented with chronic headache over a decade associated with recurrent neurological abnormalities including optic neuritis, hemisensory loss, migraine, facial nerve palsy, and recurrent vertigo. Although there was an initial perceived response to steroids, the patient had a subsequent progressive course. On investigations, she was found to have a diffused dural thickening on contrast MRI with a strongly positive Mantoux test with caseating necrotizing granulomatous inflammation on dural histology. With initiation of antituberculous medication with steroids, the patient markedly improved, and the medication for tuberculosis was continued for a year with good response. Conclusion Primary tuberculous pachymeningitis should be suspected in a patient complaining of prolonged headache with focal neurological signs when MRI evidence of dural thickening is detected, and another focus of tuberculosis was not found. Prompt suspicion with image-guided dural biopsy for histology would help to confirm the diagnosis.
Background Cranial nerve palsies are well-known complications of basal meningitis, especially in patients with tuberculous meningitis. However, a minority of bacterial meningitis gets complicated with cranial nerve palsies. Although cerebral infarctions are known to occur with acute bacterial meningitis, infarctions occurring in the brainstem are infrequently described. Case Presentation We report a 46-year-old healthy female who presented with dysarthria with fever, headache, and vomiting and was diagnosed to have acute pyogenic meningitis complicated with a brainstem infarction resulting in bilateral hypoglossal palsy. Her MRI revealed an infarction in the lower part of the medulla oblongata, probably involving the bilateral hypoglossal nuclei. Conclusion Isolated bilateral hypoglossal nerve palsy is an extremely rare cranial nerve palsy, secondary to pyogenic meningitis. To our knowledge, this should be the first reported case of isolated bilateral hypoglossal nerve palsy due to a brainstem infarct in the background of pyogenic meningitis.
Background. Eosinophilic gastroenteritis (EGE) is an uncommon disease characterized by eosinophilic infiltration of the digestive tract, which occurs due to an uncertain aetiology. Although autoimmune diseases can later present as EGE, it is unusual for EGE to have positive autoimmune antibodies without the presence of an overt autoimmune disease. Case presentation. We report a 38-year-old previously healthy man who presented with abdominal discomfort and loose stools with pleural and peritoneal effusions progressing over several weeks. His investigations revealed severe eosinophilia in peripheral blood and ascitic fluid, and a laparoscopic full-thickness biopsy from the ileum demonstrated infiltration of eosinophils in all three layers of the intestine. There were no clinical features or investigations suggestive of parasitic disease, other diseases associated with eosinophilia, or autoimmune disease. Further investigations showed a highly positive ANA, positive p-ANCA, but did not meet the criteria to diagnose a specific autoimmune disease. The eosinophilia responded to an elimination diet with gradual resolution of eosinophilia and effusions, and once it reappeared after introduction of a normal diet. Conclusion. EGE presenting as peripheral blood and ascitic fluid eosinophilia with the presence of pleural and/or peritoneal effusions is uncommon. Eosinophilic gastroenteritis can be associated with autoantibody positivity without any evidence of overt autoimmune disease manifestations. Elimination diet can be used as a potential option to prevent recurrences of EGE.
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