A Patient with Brainstem Infarction and Recurrent Fever a CaseReport

Abstract

Introduction: Bilateral medulla oblongata infarction (BMOI) is a rare subtype of all ischemic strokes often leading to tetraplegia including autonomic dysregulation. Underlying infection occurring concomitantly during initial treatment might be underdiagnosed due to overlapping symptomatic.

Case Presentation: We present a case of an immunocompetent patient with pulmonary tuberculosis, who developed acute tetraplegia following a BMOI. The patient started experiencing daily episodes of high fever shortly after the insult. After numerous initial negative screenings for tuberculosis, the recurrent fever of unknown origin pointed towards an autonomic nerve system in connection with the recent medullary lesion. However, an atypical pulmonary tuberculosis radiological presentation with a diffuse tree-in-bud sign on a Computer Tomography-scan, absent meningeal involvement in the lumbar puncture, but finally the presence of Mycobacterium Tuberculosis in tracheal secretion confirmed the diagnoses of Tuberculosis. The patient was successfully treated with quadruple therapy for two months followed by dual therapy (Rifampicin and Isoniazid) for an additional four months. This case highlights the diagnostic challenges of Mycobacterium Tuberculosis infection in an immunocompetent patient with rapid onset of tetraplegia, showing
symptoms resembling autonomic dysreflexia, typically observed in patients with spinal cord injuries at/above the T6 level, but also existent in those with ischemic medullary lesions.

Conclusion: In patients with recent BMOI and recurrent fever, tuberculosis should be always a key consideration in the differential diagnosis during the initial treatment besides the diagnoses of autonomic dysregulation.