P3B081: A Case of Headaches in a Recent Immigrant

Introduction: Altered mental status requires pediatricians to consider broad differentials, especially when presenting symptoms are nonspecific. Tuberculosis meningitis (TBM) is an insidious illness and often diagnosed late in a child's clinical course. Given the high morbidity and mortality associated with TBM, early diagnosis and management is imperative; however, drug-resistant strains and psychosocial stressors can complicate treatment course.

Case Description: A 15-year-old Hispanic male presented to the Pediatric Emergency Department (PED) with headache, generalized weakness, and epigastric pain for 1 week, along with nightmares and flashbacks for 3 months. He reported recently migrating to New York from Guatemala through Mexico mostly by foot, with 1 month in a Texas detention center. His vital signs, physical exam, and laboratory values were normal; therefore, his initial diagnosis was acute gastritis versus somatic manifestations of stress. He was discharged, but returned two days later altered and combative, requiring admission. CT head without contrast was read as normal. CSF appeared colorless with lymphocytic pleocytosis (91 UL), low glucose (17MG/DL), and high protein (228 mg/dL). ESR and CRP were elevated (62 MM/HR, 5.255 MG/DL, respectively). The patient was started on ceftriaxone and vancomycin; dexamethasone was added for persisting headache unresponsive to acetaminophen or morphine.

On hospital day 6, the patient’s headache intensified; he was no longer alert or oriented, responded only to pain, and his pupils were sluggish and dilated. His QuantiFERON resulted positive and CSF PCR was negative for common viruses and bacteria. Antibiotics were discontinued and he was started on RIPE (rifampin, isoniazid, pyrazinamide, ethambutol) therapy for presumed TBM. Subsequent MRI brain demonstrated small nodular foci, representing tuberculomas and CT chest was remarkable for miliary tuberculosis. After 22 days, he was discharged with RIPE, pyridoxine, dexamethasone, and clinical monitoring by the Department of Health (DOH).

After 5 weeks of RIPE, he returned with recurrent headaches, neck, and back pain. Repeat MRI demonstrated disease progression, evidenced by granulomas along his cervical and thoracic spine. His steroid dose was increased and acetazolamide was added to decrease intracranial pressure and levofloxacin and streptomycin were added for presumed drug-resistant TBM (DR-TBM).

Discussion: TBM is an extrapulmonary manifestation of tuberculosis associated with high morbidity and mortality. In 2021, WHO estimated a DR-TB burden of 0.87, 0.62, and 0.05 (per 100,000) in Mexico, Guatemala, and USA respectively. Immigration also influences America’s epidemiology, with increasing incidence of DR-TB along the US-Mexico border, notably Texas.

While our patient’s mycobacterial cultures eventually resulted as pan-sensitive, levofloxacin and streptomycin were added due to presumed progression of disease. After 9 months of treatment, he experienced symptom resolution.

Conclusion: TBM requires prompt evaluation and warrants high degree of clinical suspicion when caring for immigrant children. DR-TB, in conjunction with psychosocial stressors, can complicate anticipated outcomes, so tailoring antimycobacterial therapy is critical.