Objective: A case report of central nervous system (CNS) tuberculosis infection with acute parkinsonism.

Background: Neurotuberculosis is a recognized clinical entity which can present with spectrum of movement disorders such as tremor, dystonia or chorea and rarely parkinsonism. Here we present a case of an immunocompetent adult who developed parkinsonism during acute neurotuberculous infection.

Method: 29-year-old healthy gentleman presented with fever and altered behavior for 2 days. He has no history of cough, TB contact or high risk behaviour. Neurology examination showed intermittent resting tremor of the left hand and leg. There was hypomimia, bradykinesia during finger and foot taps and rigidity of all her limbs. He had difficulty to walk due to marked rigidity. Apart from that, he had bilateral pyramidal signs.

Results: Investigations showed normal total white cell count, ESR of 120mm and negative HIV ELISA. CT brain showed non enhancing white matter oedema over bilateral parietal,frontal lobes and basal ganglia.Cerebrospinal fluid (CSF) revealed high protein of 1.0 g/L and glucose level of 4.19 mmol/L with normal opening pressure. He was covered for both viral and bacterial encephalitis with intravenous acyclovir and ceftriaxone. Despite on medications for two weeks, his condition deteriorated. His CSF TB PCR and MTB culture are negative. Repeated CT brain showed multiple ring enhancing lesions suggestive of cerebral abscess over the previous edematous area. He was then started with anti-TB medication, clonazepam 0.5mg once daily, 25/100 mg of carbidopa/levodopa thrice daily and schedule for cerebral abscess drainage and biopsy. Post-surgery his condition improved, the biopsy showed pus, reactive gliosis with positive TB PCR. On follow up after 4 months, his parkinsonism had resolved.

Conclusion: This case highlights the importance of recognizing CNS tuberculous infection as part of the aetiology of acute parkinsonism which might be developed due to reversible damage to basal ganglia. To avoid treatment delay, sending pus and biopsy sample for MTB culture and TB PCR are highly recommended especially in endemic country

References: 1) Udani PM, Parekh UC, Dastur DK. Neurological and related syndromes in CNS tuberculosis (clinical features and pathogenesis) J Neurol Sci 1971;14:34157. 2) Babikian VL, Heydemann PT, Swisher CN. Extrapyramidal movements in a patient with tuberculous meningitis. Clin Pediatr 1985;24: 1135.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/intracranial-tuberculous-abcess-with-acute-parkinsonism-unusual-finding/