Paradoxical Optochiasmatic Arachnoiditis with Acute Bilateral Visual Loss During Treatment of Tuberculous Meningitis: A Case Report

Abstract

Introduction: Tuberculous meningitis (TBM) is the most severe form of central nervous system tuberculosis and is associated with significant neurological morbidity and mortality. Paradoxical reactions, characterized by clinical or radiological deterioration despite appropriate antituberculous therapy (ATT), may complicate treatment. Optochiasmatic arachnoiditis (OCA) is a rare but devastating complication that can cause irreversible visual impairment.

Aim & Objective: To highlight paradoxical optochiasmatic arachnoiditis as a rare complication of TBM and emphasize the importance of early diagnosis and aggressive anti-inflammatory management.

Case Presentation: A 24-year-old woman presented with irrelevant speech, altered mental status, headache, and vomiting. Examination revealed impaired consciousness, meningeal signs, sluggish pupils, and abnormal plantar responses. CSF showed protein of 56 mg/dL, glucose of 52 mg/dL, and lymphocytic predominance. Cartridge-based nucleic acid amplification testing detected Mycobacterium tuberculosis without rifampicin resistance. MRI demonstrated acute infarcts in the bilateral basal ganglia, genu of corpus callosum, and left amygdala, with tuberculous granulomatous lesions in the right cerebellum and pons. She was diagnosed with TBM with tuberculomas and cerebral infarctions and initiated on ATT and corticosteroids.

Result: After initial improvement, she developed paradoxical neurological deterioration with acute painless bilateral visual loss progressing to perception of light only. MRI findings were consistent with OCA. Ethambutol toxicity was considered and the drug was withheld. ATT was continued with high-dose dexamethasone and adjunctive thalidomide.

Conclusion: Paradoxical OCA should be considered in TBM patients developing visual impairment after ATT. Early recognition and aggressive anti-inflammatory therapy are crucial to prevent irreversible visual disability and differentiate the condition from ethambutol toxicity, treatment failure, and drug resistance.

REFERENCES

1. Singh AK, Malhotra HS, Garg RK, Jain A, Kumar N, Kohli N, et al. Paradoxical reaction in tuberculous meningitis: presentation, predictors and impact on prognosis. BMC Infect Dis. 2016;16:1-11. https://doi.org/10.1186/s12879-016-1625-9.
2. Garg RK, Malhotra HS, Kumar N. Paradoxical reaction in HIV-negative tuberculous meningitis. J Neurol Sci. 2014;340(2):26-36. https://doi.org/10.1016/j.jns.2014.03.025
3. Garg RK, Paliwal V, Malhotra HS. Tuberculous optochiasmatic arachnoiditis: a devastating form of tuberculous meningitis. Expert Rev Anti Infect Ther. 2011;9(9):719-729. https://doi.org/10.1586/eri.11.93
4. Anupriya A, Sunithi M, Maya T, Goel M, Alexander M, Aaron S, et al. Tuberculous optochiasmatic arachnoiditis. Neurol India. 2010;58(5):732-735. https://doi.org/10.4103/0028-3886.72194
5. Sinha MK, Garg RK, Anuradha HK, Agarwal A, Singh MK, Verma R, et al. Vision impairment in tuberculous meningitis: predictors and prognosis. J Neurol Sci. 2010;290(1-2):27-32. https://doi.org/10.1016/j.jns.2009.12.012
6. Sinha MK, Garg RK, Anuradha HK, Agarwal A, Parihar A, Mandhani PA. Paradoxical vision loss associated with optochiasmatic tuberculoma in tuberculous meningitis: a report of 8 patients. J Infect. 2010;60(6):458-466. https://doi.org/10.1016/j.jinf.2010.03.013
7. World Health Organization. WHO consolidated guidelines on tuberculosis. Module 4: treatment – drug-susceptible tuberculosis treatment. Geneva: World Health Organization; 2022:1-72. https://doi.org/10.2471/b09341
8. Schoeman JF, Andronikou S, Stefan DC, Freeman N, van Toorn R. Tuberculous meningitis-related optic neuritis: recovery of vision with thalidomide in 4 consecutive cases. J Child Neurol. 2010;25(7):822-828. https://doi.org/10.1177/0883073809350507
9. Schoeman JF, Fieggen G, Seller N, Mendelson M, Hartzenberg B. Intractable intracranial tuberculous infection responsive to thalidomide: report of four cases. J Child Neurol. 2006;21(4):301-308. https://doi.org/10.1177/08830738060210040801
10. van Toorn R, Solomons RS, Seddon JA, Schoeman JF. Thalidomide use for complicated central nervous system tuberculosis in children: insights from an observational cohort. Clin Infect Dis. 2021;72(5):136-143. https://doi.org/10.1093/cid/ciaa1826