A Rare Case Of Cavernous Sinus Syndrome in a Patient with Tuberculous Meningitis

The incident of Tuberculosis (TB) in Malaysia is estimated 81.4 per 100,000 population [1]. In 2011, the number of extra pulmonary TB reported was 2888 cases [1]. Reported cases of extra pulmonary TB in Malaysia noted to be increasing in trend over the years based on statistic from 2005 to 2011 [1]. Although the prevalence of TB meningitis is low, it has high mortality and morbidity if inadequately treated. Presentation of TB meningitis varies from chronic headache, neurological abnormalities to behavioural changes. As TB is endemic in Malaysia, TB meningitis is one of differentials in patient who presents with signs and symptoms of CSF infection. CSF in TB meningitis have the characteristic finding of elevated CSF protein with low CSF sugar. CSF direct smear for acid fast bacilli may not yield any findings. As CSF Mycobacterium Tuberculosis (MTB) has sensitivity of 40 to 60 percent [2] and newer method namely CSF for TB PCR has sensitivity of 44.5 percent and specificity of 92.0 percent [1], the definitive diagnosis of TB meningitis could prove to be challenging at times. The diagnosis of TB meningitis highly relies on high index of suspicion based on presentation and clinical findings, aided with characteristic of CSF findings and radio imaging [3]. Treatment needed to be commenced early despite pending CSF culture in order to reduce mortality and morbidity. We report a rare case of TB meningitis presenting with bilateral cavernous sinus syndrome.