Severe headache • neck pain • intermittent cough • Dx?

Treatment should be given for a total of 9 to 12 months

Initiate treatment for TB based on a strong clinical suspicion for the disease. Treatment of TBM consists of an intensive phase with 4 anti-TB drugs for 2 months (typically INH 800 mg/d, rifampin 450 mg/d, pyrazinamide 1000 mg/d, and ethambutol 800 mg/d) and a continuation phase with 2 drugs (INH and rifampin) for 7 to 10 additional months, resulting in a total treatment duration of 9 to 12 months.

Our patient was discharged from the hospital after 2 weeks on an anti-TB medication regimen of INH, rifampin, and pyrazinamide, along with pyridoxine and a tapering dose of dexamethasone. After the initial 2 months of intensive phase therapy, she was switched to INH 300 mg/d and rifampin 450 mg/d for the continuation phase. The patient followed up at our family medicine outpatient clinic with slow improvement of her muscle weakness before returning to China once she was placed on the continuation phase drugs.

THE TAKEAWAY

Suspect TB in high-risk patients traveling from endemic areas. Our patient, a Chinese woman visiting Brooklyn, New York, should’ve been considered high risk for TB even without her travel history from China because Brooklyn has a high rate of TB, as well. (In 2015, Sunset Park, Brooklyn had 18.2 cases of TB per 100,000 people, which was more than double the citywide rate.⁷)

TBM is a subacute disease with an often subtle presentation. Once you suspect TBM, isolate the patient, obtain appropriate cultures and smears, and start anti-TB drugs and adjunctive corticosteroids immediately, while the results of studies for AFB are still pending. Prompt diagnosis and treatment can save a patient’s life.