How to manage headaches in chronic infective granulomas?

Question

Hi doctor,

The patient is a 28-year-old male. His weight is 123.46 lb, and his height is 6 feet. He was an assistant professor. For around five days, He had a severe, unbearable headache, high fever, vomiting, loss of appetite, lost consciousness and had a single episode of seizure on the fifth day. He was admitted to the intensive care unit (ICU) in the hospital and was discharged after 10 days. He had a magnetic resonance imaging (MRI) brain with contrast after one day of my admission, and it suggested chronic infective granulomas with leptomeningeal involvement. The other tests were cerebrospinal fluid (CSF) GeneXpert negative, CSF adenosine deaminase (ADA) negative. TB medication - anti-tuberculosis drugs (AKT) 4 was started along with tablet Levipil 500, tablet Benadon 40, tablet Pan 40 and tablet Wysolone (40, 30, 20, 10 and 5 mg dose reduction). His current symptoms are frequent, bearable headaches every day. The Headache may continue for an hour. It has been nearly one month, and I still have a headache, but the amplitude of the headache is less than that during and before hospitalization. Please give us suggestions for follow-up.

Answer 1

Hello,

Welcome to icliniq.com.

As per the given history and reports, it seems that the patient had meningoencephalitis. The probable cause may be tuberculosis. Magnetic resonance imaging (MRI) also showed granulomas with leptomeningeal involvement in the brain, and the patient is currently on four-drug ATT (antituberculosis treatment) with oral steroids. As the patient has had mild headaches for the last month, there is a need to consider the possibility of hydrocephalus (enlargement of ventricles in the brain) and tuberculosis bacteria being resistant to ATT. A favorable thing is that GeneXpert is negative, so less chance of being resistant to tuberculosis bacteria (TB). Mild bearable headaches can also be associated with secondary depression, which many patients develop with any chronic illness.

The investigations to be done are

Repeat MRI brain with contrast to look for any hydrocephalus, status of granulomas - improving or newly developing.
Fundus examination to look for any papilledema.
Regular LFT (liver function test) checkup to look for any hepatotoxicity developing due to ATT. Treatment plan includes- If repeat MRI shows worsening of granulomas, then the patient can be considered to start on fifth ATT - Injection Streptomycin or tablet Levofloxacin (only after consulting neurologist).

I hope this helps.

Thank you.