Annals of Long Term Care

Tuberculosis (TB), caused by Mycobacterium tuberculosis, is a highly infectious airborne disease that is classified based on disease symptoms and site of infection. When TB affects the lungs, which is the most common presentation, it is called pulmonary TB. When other parts of the body are infected, this is referred to as extrapulmonary TB. Some common sites of extrapulmonary infection include the lymph nodes, genitourinary tract, peritoneum, skin, pericardium, and meninges. We report a case of TB meningitis in an 89-year-old woman that proved difficult to diagnose, as is typical in elderly individuals. We also discuss the incidence and diagnosis of extrapulmonary TB infections in older patients and highlight the importance of early diagnosis in this population, as these patients tend to experience delays in diagnosis and, subsequently, increased morbidity and mortality, as indicated by autopsy studies.

Case Presentation
An 89-year-old woman, originally from Haiti, was admitted to the geriatrics service of an inner-city teaching hospital for a 1-week history of diffuse abdominal pain, nausea, vomiting, and fever. She had presented to the emergency department 2 days earlier with the same symptoms, but her workup was unrevealing and she was discharged to home with a recommendation to take acetaminophen to reduce her pain and fever. Upon being admitted to the geriatrics service for persistent symptoms, a review of systems was positive for mild chronic headache and neck aches, but no cough, shortness of breath, neck stiffness, chest pain, or changes in cognition were evident. The patient’s medical history included chronic headaches and neck pain for 5 years, cholelithiasis, gastroesophageal reflux disease, diverticulosis, degenerative joint disease, and uterovaginal prolapse. Her regular medications included oxybutynin, omeprazole, and acetaminophen. The patient had moved to the United States from Haiti in 2005 to be with her family, and her last visit to Haiti was over 1 year before her current presentation.

The patient’s vital signs on admission revealed a temperature of 37.2°C, pulse of 95 beats per minute, blood pressure of 146/79 mm Hg, and respiratory rate of 18 breaths per minute. The physical examination was notable for a diffusely tender abdomen. Cardiac, pulmonary, and neurological examinations were normal, and the patient’s family reported no changes in mental status or cognition. Abnormal laboratory findings were restricted to a serum sodium concentration of 130 mEq/L (normal, 136-142 mEq/L) and a serum alkaline phosphatase of 170 U/L (normal, 30-120 U/L). A chest radiograph revealed small bilateral pleural effusions, but was otherwise clear. During hospitalization, the patient had persistent abdominal pain, nausea, vomiting, temperature spikes to 39.4°C, headache, and neck pain.

Based on the patient’s history and abdominal symptoms, the initial workup focused on an acute abdominal process. Once this was ruled out by multiple imaging studies, other causes of her fever were investigated. Blood and urine cultures and tests for various pathogens were negative, including influenza, human immunodeficiency virus, syphilis, Legionella, and malaria. A transthoracic echocardiogram was negative for valvular vegetations and a computed tomography scan of the brain showed only chronic small-vessel changes. Eventually, a tuberculin skin test and a lumbar puncture were performed. The patient’s cerebrospinal fluid (CSF) revealed a protein count of 291 mg/dL (normal, 15-45 mg/dL), glucose of 11 mg/dL (normal, 40-70 mg/dL), and a white blood cell count of 216/µL (normal, <250/µL), with 17% neutrophils and 81% lymphocytes.

The patient’s tuberculin skin test revealed a 16-mm induration. By report, the patient had no known history of TB, and it was unclear whether she had ever received the Bacille Calmette-Guérin (BCG) vaccine.