A 43-year-old man, who has been abusing alcohol and suffering from pulmonary tuberculosis, in the course of two weeks gradually developed general weakness, headache, diplopia, vomiting. Objectively: ptosis on the left, anisocoria S>D, exotropia of the left eye, neck stiffness; Kernig's and Brudzinski's signs are positive. In cerebrospinal fluid: lymphocytic pleocytosis, low glucose, precipitation of cerebrospinal fluid resulted in production of fibrin film. What is the most likely diagnosis?

Answer options

1. Basal arachnoiditis
2. Tuberculous meningitis
3. Acute myelitis
4. Brainstem encephalitis
5. Subarachnoid hemorrhage

Explanation

A 43-year-old man, who has been abusing alcohol and suffering from pulmonary tuberculosis, in the course of two weeks gradually developed general weakness, headache, diplopia, vomiting. Objectively: ptosis on the left, anisocoria S>D, exotropia of the left eye, neck stiffness; Kernig’s and Brudzinski’s signs are positive. In cerebrospinal fluid: lymphocytic pleocytosis, low glucose, precipitation of cerebrospinal fluid resulted in production of fibrin film. What is the most likely diagnosis?A. Tuberculosis meningitis in the analysis of cerebrospinal fluid is characterized by lymphocytosis, a decrease in glucose, and the formation of a fibrin film. Considering the presence of pulmonary tuberculosis, it is possible to diagnose tuberculous meningitis. B. A subarachnoid hemorrhage is characterized by a sharp, sudden headache, often cerebral symptomatology. Subarachnoid hemorrhage is characterized by the presence of blood in the cerebrospinal fluid; therefore, this diagnosis can be excluded. C. Stem encephalitis is characterized by vertigo, ataxia, nystagmus, impaired breathing, and cardiac activity. The cerebrospinal fluid is characterized by lymphocytosis without changing the glucose level and without the formation of a fibrin film, so this diagnosis can be excluded. D. An acute myelitis is characterized by the appearance of pathological reflexes, motor, and sensory disorders. In the cerebrospinal fluid, it is possible to detect protein cell dissociation. Reducing the level of glucose and the formation of fibrin film for acute myelitis is not typical. E. Basal arachnoiditis is characterized by cerebral and focal symptomatology. In the analysis of cerebrospinal fluid, minor lymphocytic pleocytosis and protein-cell dissociation can be detected. Thus, the clinic-laboratory data described in the task allow excluding the diagnosis of “basal arachnoiditis.” Based on the presence of tuberculosis of other localization, an aggravating factor in the anamnesis – alcoholism, a gradual accumulation of symptoms of the disease, characteristic changes in the cerebrospinal fluid: a decrease in the amount of glucose less (½ of its content in the blood), increased protein, lymphocytic pleocytosis, prolapsed fibrin film within a few hours, it is possible to confirm the diagnosis of tuberculous meningitis.