Department of Neurology, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, Düsseldorf, 40225, Germany.
Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Münster, 48149, Germany.
BMC Neurol. 2023 Jul 3;23(1):256. doi: 10.1186/s12883-023-03308-1.
Tuberculous meningitis, a rare but severe form of extrapulmonary tuberculosis, frequently affects cranial nerves. While nerves III, VI and VII are commonly involved, involvement of caudal cranial nerves is rarely described. Here, we report a rare case of bilateral vocal cord palsy secondary to caudal cranial nerve involvement in tuberculous meningoencephalitis, that occurred in Germany, a country with low tuberculosis incidence.
A 71-year-old woman was transferred for further treatment of hydrocephalus as a complication of presumed bacterial meningitis with unknown pathogen at that time. Because of decreased consciousness, intubation was performed and an empiric antibiotic therapy with ampicillin, ceftriaxone and acyclovir was initiated. Upon admission to our hospital, an external ventricular drainage was placed. Cerebrospinal fluid analysis revealed Mycobacterium tuberculosis as the causative pathogen, and antitubercular treatment was initiated. Extubation was possible one week after admission. Eleven days later, the patient developed inspiratory stridor that worsened within a few hours. Flexible endoscopic evaluation of swallowing (FEES) revealed new-onset bilateral vocal cord palsy as the cause of respiratory distress, which required re-intubation and tracheostomy. The bilateral vocal cord palsy persisted despite continued antitubercular therapy on the follow-up examination.
Considering the aetiology of infectious meningitis, cranial nerve palsies may be suggestive for tuberculous meningitis as underlying disease given their rarity in other bacterial forms of meningitis. Nevertheless, intracranial involvement of inferior cranial nerves is rare even in this specific entity, as only extracranial lesions of inferior cranial nerves have been reported in tuberculosis. With this report of a rare case of bilateral vocal cord palsy due to intracranial involvement of the vagal nerves, we emphasize the importance of timely initiation of treatment for tuberculous meningitis. This may help to prevent serious complications and associated poor outcome since the response to anti-tuberculosis therapy may be limited.
结核性脑膜炎是一种罕见但严重的肺外结核形式，常累及颅神经。虽然第三、六和七对颅神经经常受累，但很少描述尾部颅神经受累。在此，我们报告一例罕见的因结核性脑膜脑炎累及尾部颅神经引起的双侧声带麻痹病例，该病例发生在德国，一个结核病发病率较低的国家。
一名 71 岁女性因疑似细菌性脑膜炎的并发症脑积水被转来进一步治疗，当时该患者的病原体未知。由于意识下降，进行了气管插管，并开始经验性使用氨苄西林、头孢曲松和阿昔洛韦进行抗生素治疗。入院时，放置了外部脑室引流管。脑脊液分析显示分枝杆菌结核是致病病原体，并开始抗结核治疗。入院后一周可以拔管。入院 11 天后，患者出现吸气性喘鸣，数小时内病情加重。经口进饮食的灵活内镜评估（FEES）显示新发性双侧声带麻痹是导致呼吸困难的原因，需要重新插管和气管切开。尽管在后续检查中继续进行抗结核治疗，但双侧声带麻痹仍持续存在。
鉴于感染性脑膜炎的病因，如果其他细菌性脑膜炎中很少见颅神经麻痹，则可能提示存在结核性脑膜炎。然而，即使在这种特定疾病中，颅神经的颅内受累也很少见，因为在结核病中仅报道了颅神经的颅外病变。通过报告一例罕见的因颅内迷走神经受累导致双侧声带麻痹的病例，我们强调及时开始结核性脑膜炎治疗的重要性。由于抗结核治疗的反应可能有限，因此这有助于预防严重并发症和相关不良结局。
