Cerebral Tuberculosis Presenting as Complex Febrile
Convulsions
By Chr. f3erger1, Chr. P. ~raegge?, Manuela ~ l b i s e f t i ' Klara
,
~ a n d a uand
~ D. Idadall
'~nfectiousDiseases Unit and 2~astroenterologyUnit, University CMdren's Hospital of Ziirich and 3~epartmentof Ophthalmology,
University Hospital Ziirich, Switzerland

Complex febrile convulsions were the initial
clinical manifestation of miliary tuberculosis in a 4-year-old
immigrant girl. The cerebral lesions were visible only after
contrast-enhancedcranial computed tomography (CT)wlde
native CT scan as well as cell count and glucose concentration in the cerebrospinal fluid were normal. Mycobacterium
tuberculosis was cultured £rom gastric aspirate and liver
biopsy tissue. Treatment with isoniazid and rifampin for 12
months, pyrazinarnide for 9 months, and ethambutol for the
initial 6 weeks resulted in resolution of the cerebral lesions
but a retinal scar aRer granuloma formation in the right eye
caused reduced visus. This case demonstrates the importance of thorough search for tuberculosis even in the absence
of overt c h c a l pulmonary signs especially in high-risk
inaviduals such as immigrants.

Key words

M a r y tuberculosis - Febrile convulsions Children - Central nervous system

Abbreviations
BCG: bacille Calmefte G u h n
CNS: central nervous system
CSF: cerebrospinal fluid
C T computed tomography

of cerebrospind fluid (CSF) examination and native cranial
computed tomography (CT) may be misleading. Awareness of
ths may prompt for additional investigations and allow for
timely initiation of treatment and prophylactic measures
against tuberculosis, the latter especially in the light of the
re-emergence of this infection in cerbin developed countries.

Case report
The 4-year-old girl was admitted to our hospital because of complex febrile convulsions. After generalized
tonic-clonic convulsions with deviation of the eyes the mother
had administered rectally diazepam (5 mg). Two episodes of
febnle seizures had occurred 6 and 12 weeks before. Further
past m&cal and family history were unremarkable. It was
uncertau~whether BCG-vaccination had been given aRer birth
in Peru, from where she had immigrated to SwitzerIand two
months before admission.

On admission, the girl was unconscious and in
reduced general condition. H
errectd temperature was 38.6 "C;
she showed nystagmus to the left side, delayed left-sided
pupdlary reachon, no pain reaction and increased tmdonreflexes of the right leg. Physical examination of the heart
and lungs revealed no a b n o d t i e s . W i h two hours following injection of phenobarbital (6 mg/kg) neurologic symptoms
resolved completely.
Laboratory work-uprevealed leukocytes 1 4 . 4 ~

109A (75% band forms, 16% lymphocytes), erythrocyte sedimentation rate 28 mmh, C-reactive protein 165 m a and

normal values for hemoglobin, platelets, clotting parameters,
serum glucose and calcium. Examination of CSF showed 2
monocytes/pl, glucose 3.25mmoM but elevated protein
0.79 g/l.
Because of persisting unexplained fever a chest
Introduction
x-ray was performed two days later whch revealed diffuse
'Ibenty percent of febrile convulsions are com- rniliary lesions and right hilar adenopathy. To disclose the
plex, i.e. last for more than 15 minutes, are focal or recur (8). etiology bronchoalveoIar lavage rapidly, aspiration of gastric
Neurolo~cand metabolic diseases, meningitis and other in- fluid and bone marrow, fine needle biopsy of the liver and a
tracerebra1 mfections should be sought. The here reported 4- second lumbar puncture were done. Cranial CT scan demonyear-old gul with febrile s e h e s as first clinical sign of miliary strated slightly enlarged ventricles. Only after contrast-injection
tuberculosis severely involving the central nervous system multiple small annular parenchymal lesions and some circum(CNS) and multiple other organs demonstrates that i'indings scribed mass lesions could be seen (Fig. 1).Fundus examination
showed a large elevated choroidal lesion infratemporal to the
right papilla with a retinal hemorrhage in the center of the
Received July 12, 1995; revised, accepted December 4, 1995
macda (I:&. 2). Multiple smaller choroidal lesions were seen in
both eyes. A b d o d CT scan revealed one granuloma each in
Neuropediatrics 27 (1996) 161-163
Q Hippokrates Verlag Stuttgart
the spleen (diameter 1 cm) and in the left adrenal gland

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Abstract

162 Neuropediatrics 27 (1996)
-

Chr. Bergn et a1

be exduded high-dose cotnmoxazole (120 mg'kg/day) was
added to the treatment until cultures of gastric aspirate and
of liver biopsy grew Mycobacterium tuberculosis 12 days later.
The isolate was susceptible to the antituberculous drugs administered. Examination of household members revealed no index
case. The girl was discharged afLer 30 days; 2 weeks later, she
experienced a right-sided seime that was coped with rectal
diazepam (5 mg). A cranial CT scan showed reduced number
and size of the cerebral lesions. The further course under
phenobarbital medcation was uneventful. Ocular examination
18 months Iater showed hand motion vision with secondary
exotropia in the right eye caused by an atrophc chorioretmal
scar in the posterior pole; chest roentgenogram and cranial CT
scan were normal.

Miliary tuberculosis involving the CNS, eyes,
lung, liver, spleen and adrenal gland in the reported child
marufested c h i c a l l y as complex febnle convulsion. The presenhg picture of d a r y tuberculosis is often unspecific, chest
x-ray and skm test being false negative (3, 5). Because &ssemination to the CNS and subsequent progressive CNS &sease
is the form of extrapulmonary tuberculosis that develops most
rapidly in children after primary infedion, they may present
initially, as our patient, with neurological rather than with
Fig. 1 Cranlal computed tomography of a 4-year-old glrl wlth complex puLmOnarysymptoms'
febrile convulsions as presenting cllnlcal plcture of millary tuberculosis.
Dissemination of Mycobacteriurn tuberculosis
The cerebral lesions were only visible after contrast injection.
to extrapulmonary sites occurs more often in clvldren than in
adults (3) and complicates approximately 20% to 25% of
tuberculous disease in children (10). Mliary tuberculosis results from profuse hematogenous spread of a primary tuberculosis and accounts for 1% to 3% of extrapulmonary tuberculosis (10). Early evidence of dissemination was seen in liver
biopsies, shown as early diagnostic tool in children beside
morning gastnc aspirate and bone marrow biopsy (3).
Infechon with Mycobacterium tuberculosis involving the CNS may present as meningitis, solitary tuberculoma, abscess, infarct or, as in the reported girl, as miliary
parenchymal dsease (3).Although dssemination to the CNS is
common during rmlary disease, chcally apparent meningitis
complicates only approximately 20 % of cases (3, 5). Of-note
lesions withut the brain may be visible only in contrast-enhanced CT irnagmg stuhes and in fact be associated with CSF
h h g s (2, 7)slrmlar to our patient who had only elevated CSF
fig. 2 Fundus photograph of a 4-year-old girl with mlllary tuberculosis.
Mametic resonanceimaging with contrast a&straNote the Inflammatory mass, a choroldal tuberculoma, lnfratemporal to tion may detect even smallerfoci (2). choroidd tubercles
the right papilla.
round wbtish lesions) and tuberculomas (large inflammatory
masses) represent the most common fonn of ocular involvement
(diameter 1.5cm) as well as enlarged retroperitoneal lymph in tuberculosis. Such lesions are indicative of hematogenous
nodes.
spread of bacilli and occur mostly in children (4, 9).
Microscopy of the bronchoalveolar lavage
The outcome and sequelae of treated miliary
showed two incompletely staining acid-fast rods compatible
tuberculosis
are
primarily correlated to the presence of meninwith either mycobacteria or nocardia. Tubmulostearate was
gitis
and
the
stage
of meningitis in that therapy was initiated (3,
not detectable in the CSE Histology of liver biopsy showed
?he
mowty
rate is 19%, mwinStis being the only
multiple epitheloid cell granulomas, but not acid-fast rods. The
significant
risk
factor
for death (5).
intraderma1 tuberculin test (2 IU PPD-RT23) showed 3 mm
induration.
The incidence of tuberculosis in the United
An antituberculous regimen consisting of iso- States increased in recent years and is there, as in Westem
niazid (10 rng/kg/d) and rifampin (10 mgflrg/d) for 12 months, European countries, hghest in young people, in immigrants
pyrazinamide (25 mg/kg/d) for 9 months and etharnbutol for born in a country with hgh prevalence of tuberculosis (1, 6)
the initial 6 weeks was started. Because nocardiosis could not and in HN-infected individuals. Thus, tuberculosis should be

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Discussion

Cerebral Tuberculosis Presenting as Complex Febrile ConvuIsions

sought in all children h m immigrants, even in the absence of
overt clinical pulmonary signs and symptoms. This will allow
for timely treatment of affected children and identification and
treatment of contagious adults.

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PD Dr. D. Nadul
University Children'sHospital
SLeinwiesstrasse75
CH-8032Ziirich
Switzerland

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* Gee, G. T., C. Bnan,J. R. Jinkins:EVWlary tube~culosisin involving the