Correspondence
Case 11-2007: Neck Pain, Weakness, and Cranial-Nerve Palsies
N Engl J Med 2007; 357:197July 12, 2007
- Article
To the Editor:
In the discussion of Case 11-2007, which involved a 59-year-old man with Lyme disease, Greer et al. (April 12 issue)1 did not consider the differential diagnosis of tubercular meningitis. In a patient with a long history of symptoms, the presence of multiple cranial-nerve palsies, a low neutrophil count, and high levels of protein and glucose in the cerebrospinal fluid, the possibility of a potentially curable mycobacterial infection should be considered.2 Although the patient had negative microbiologic findings, in adults with clinical tubercular meningitis, the acid-fast smear and mycobacterial culture of cerebrospinal fluid both have a low sensitivity for the diagnosis (58% and 71%, respectively, in one study3).
3 ReferencesNishith K. Singh, M.D.
Southern Illinois University School of Medicine, Springfield, IL 62794
nishith_singh2007@yahoo.com 1
Case Records of the Massachusetts General Hospital (Case 11-2007). N Engl J Med 2007;356:1561-1570
Full Text | Web of Science | Medline2
Thwaites GE ,Chau TT ,Stepniewska K , et al. Diagnosis of adult tuberculous meningitis by use of clinical and laboratory features. Lancet 2002;360:1287-1292
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Thwaites GE ,Chau TT ,Mai NT ,Drobniewski F ,McAdam K ,Farrar J . Tuberculous meningitis. J Neurol Neurosurg Psychiatry 2000;68:289-299[Erratum, J Neurol Neurosurg Psychiatry 2000;68:802.]
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To the Editor:
In the discussion of the case involving a patient who presented with descending paralysis and cranial-nerve palsies that progressed to respiratory failure, botulism should have been considered in the differential diagnosis.1
1 ReferencesAmer A. Alkhatib, M.D.
Fateh A. Elkhatib, M.D.
Holy Family Hospital, Spokane, WA 99208
khatibamer@yahoo.com 1
Arnon SS ,Schechter R ,Inglesby TV . Botulinum toxin as a biological weapon: medical and public health management. JAMA 2001;285:1059-1070[Erratum, JAMA 2001;285:2081.]
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Author/Editor Response
Singh appropriately mentions the possibility that the patient had tubercular meningitis, although several features make this diagnosis unlikely. Patients with tubercular meningitis may present with a subacute course, with fevers and general malaise. Furthermore, cranial neuropathies are common, including those involving the sixth and seventh nerves, as in this patient.1 Spinal meningitis also may occur, although it is less common.2 In this condition, radiculomyelopathy or transverse myelitis may develop. Notably absent in this patient, however, was a history of exposure to persons known to have tuberculosis; with the positive test for Lyme disease, as well as the known exposure to tick bites in an endemic area, the diagnosis of tuberculosis as the cause of his meningitis was thought to be extremely unlikely.
Alkhatib and Elkhatib comment that this case may be suggestive of botulism. Botulism most commonly presents as a descending, symmetric, flaccid paralysis with hyporeflexia or areflexia. Cranial-nerve palsies can occur and may involve the sixth and seventh nerves, with an occasionally asymmetric presentation.3 Respiratory failure can also occur. However, the condition is usually painless, fever is uncommon, and the cerebrospinal fluid is normal, findings that essentially rule out botulism in this patient.
3 ReferencesDavid M. Greer, M.D., M.A.
Harvard Medical School, Boston, MA 021151
Traub M ,Colchester AC ,Kingsley DP ,Swash M . Tuberculosis of the central nervous system. Q J Med 1984;53:81-100
Web of Science | Medline2
Sheller JR ,Des Prez RM . CNS tuberculosis. Neurol Clin 1986;4:143-158
Web of Science | Medline3
Penas SC ,Faria OM ,Serrao R ,Capao-Filipe JA ,Mota-Miranda A ,Falcao-Reis F . Ophthalmic manifestations in 18 patients with botulism diagnosed in Porto, Portugal between 1998 and 2003. J Neuroophthalmol 2005;25:262-267
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