P3.G137: A Global Health Threat in the Southern Border Region: A Case of Pediatric Tuberculosis Meningitis in an International Patient Complicated by a Recent Paternal Loss

Introduction: The patient is a 5-year-old male with 3-weeks of illness that began after his father's death. He had experienced headaches, fatigue, diarrhea, fever, cough, and abdominal pain, coupled with reduced appetite. According to his mother, he had not been himself since his father succumbed to "heart failure," although she cannot recall the specific details. Given that the child often shared a bed with his father and assisted in his care, she initially attributed his symptoms to grief. Despite consulting physicians on both sides of the border and being treated with antibiotics, he was eventually brought to the ER for evaluation.

Case Description: On arrival, his vitals and physical exam were as follows: temperature 38°C, BP 128/94, RR 28, HR 112. General: tired, arousable. HEENT: normocephalic, PERRLA, dry mucous membranes, minimal cervical lymphadenopathy. Heart: RRR, no murmur, pulses intact. Abdomen: mild RLQ tenderness, normal bowel sounds, psoas/obturator negative. Skin: No rashes. Neurologic: AAO, no focal deficits, normal strength, normal gait, reflexes symmetric.
An abdominal ultrasound and X-ray were normal. Chest X-ray showed congestion consistent with a viral URI. A CT abdomen revealed mild hepatomegaly. Labs demonstrated leukocytosis of 23k without bandemia, CRP 0.23, UA normal, and normal hepatic enzymes. He also had rhinovirus on viral PCR. A CT head showed mild sinusitis. A head MRI revealed sinusitis and cervical lymphadenopathy. Tuberculosis IGRA, EBV, and CMV titers were collected. Due to leukocytosis, headaches, and prolonged fever, a lumbar puncture was performed with the following results: colorless, RBC 119, WBC 39, GLU 17, PRO 108. Subsequently, he was started on antibiotics for meningitis. The following day, he developed a seizure with unresponsiveness, stiffness, and left-ward fixed gaze. He was post-ictal and altered but repeat CT head was unremarkable.

Discussion: The tuberculosis IGRA returned positive, and he was started on rifampin, isoniazid, pyrazinamide, and ethambutol. He improved with treatment, had no further seizures, and was discharged on RIPE therapy. Weeks later, his CSF AFB culture returned positive for Mycobacterium tuberculosis. The source of the patient’s infectious contact was likely his father as his mother, upon reviewing her husband’s medical information, learned that his cause of death was listed as “consumption”. A confounder that delayed diagnosis was the timing between his paternal loss and the start of his symptoms which were disregarded as psychosomatic by several physicians in both countries.

Conclusion: Pediatric tuberculosis meningitis is rare in the United States yet remains a global health threat. As more international patients from countries where tuberculosis is endemic continue to migrate to the US or live in a foreign country but seek healthcare access in the US, tuberculosis cases may continue to rise. Therefore, it is important to consider it as a differential and stay compliant with the latest treatment guidelines.