Neurotuberculosis in a Patient with CKD: A Rare Case Report of the Lethal Duo

Introduction: One of the leading causes of deaths worlwide has been infections with Mycobacterium tuberculosis (TB), which is endemic in certain nations where also prevalance of CKD has been on an rising trend. In patients with CKD, the incidence of TB has been 10–15 times greater than that in the general population, considering the immunocompromised state associated with CKD.The clinical presentation of TB in CKD patients is often insidious and atypical. Patients frequently present with symptoms like fever, anorexia, and weight loss which may mimic uremia and mask diagnosis of Nuero-tuberculosis. Case Description: A 66 year old gentlemen, a known case of CKD stage V due to underlying diabetic Nephropathy , presented with complains of easy fatigabilty since a month.He was found to have a right sided plueral effusion and a serum creatinine of 5.6 mg/dl. Subsequently patient underwent a diagnostic tap which favoured diagnosis of extra-pulmonary TB (pleural fluid: cells- 550/cumm lymphocytes-90%, ADA- 54 IU/L , lights criteria ratio-1.2 ). Patient was started on Anti-tubercular drug therapy as per National TB guidelines including Isoniazid, Rifampicin, ethambutol and Pyrazinamide as per weight based dosing and dose adjusted for CKD staging. Two weeks later patient complained of uremic symptoms and drowsiness. On further investigations, he had urea of 157 mg/dl, creatinine of 8.4 mg/dl demanding initiation of hemodialysis. After initial 3 sessions of hemodialysis patient did not show any improvement and underwent an MRI Brain with diffusion imaging suggestive of a T2 heterointense lesion measuring 1.20 x 1.28 cm is seen in left posterior frontal lobe showing mild perilesional edema and heterogeneous diffusion restriction on DWI images. On the context of an established extra-pulmonary TB and the intra-parenchymal CNS lesion a diagnosis of Tuberculoma was made. Discussion: Tuberculomas, occur secondary to a primary infection, the focus being lungs or lymph nodes, occuring in the background of CKD is a very rare extrapulmonary manifestation of TB. The performance of TB screening and diagnostic tests is suboptimal in the CKD population, making a timely diagnosis a challenging task. Considering the high prevalance of CKD in TB endemic areas, a missed diagnosis of TB in CKD population could have significant public health implications and poor patient outcomes.