Title : Rifampicin-resistant meningeal tuberculosis in an immunocompromised patient with HIV: Case report
Abstract:
Male patient, 35 years old, with a personal history of HIV diagnosis one year ago with irregular treatment, and pulmonary tuberculosis infection with complete treatment and discharge due to cure two years ago, resident of a free area, cocaine user, with grade III malnutrition. He was admitted to an emergency room with a history of asthenia, general decline, and loss of appetite. During treatment, he developed decreased consciousness and decorticate posture, undergoing orotracheal intubation for airway maintenance. Initial laboratory tests showed mild anemia, leukocytosis with left shift, and hyponatremia. Non-contrast cranial tomography showed a faint hypoattenuating area in the right thalamocapsular region, heterogeneous and poorly defined, with no significant expansive or retractive effect. Mild diffuse brain atrophy and calcified carotid and vertebrobasilar atheromatosis were also observed. Empirical antibiotic therapy with ceftriaxone was initiated. Given the suspicion of neuroinfection, the patient was transferred to a referral hospital for infectious diseases. Upon admission, he was hemodynamically stable, under invasive mechanical ventilation in pressure-controlled mode, with continuous sedation and analgesia, and low ventilatory parameters. Treatment with sulfamethoxazole-trimethoprim (due to suspected pneumocystosis), COXIP regimen, and corticosteroid therapy with dexamethasone was instituted. Laboratory tests on admission showed mild anemia (Hb: 10.9 mg/dL), elevated ferritin (2,000 ng/mL), and increased CRP (116 mg/L). Cerebrospinal fluid obtained by lumbar puncture revealed elevated protein (185 mg/dL), reduced glucose (12 mg/dL), increased lactate (62.6 mg/dL), and leukocytosis (295 cells/mm³) with a predominance of neutrophils (55%). Gram staining showed Gram-positive cocci, India ink staining was negative for encapsulated yeasts, and the bacterial capsular antigen (latex) test was nonreactive. The GeneXpert molecular test detected rifampicin-resistant Mycobacterium tuberculosis in both the cerebrospinal fluid and tracheal secretions. BAAR testing in tracheal secretions was positive (2 crosses). The viral load for HIV was 314,000 copies, with CD3 count: 424, CD4: 130, and CD8: 275 cells/mm³. The patient, who was immunocompromised and severely malnourished, had an unfavorable outcome, with difficult weaning from ventilation due to neurological impairment. He underwent tracheostomy after 13 days of orotracheal intubation and died after 21 days of hospitalization.
