Tuberculous Meningitis Missed After a Language Gap

Key TakeawaysA 30-year-old man presented with fever, general weakness, and reduced oral intake. Because of a language barrier, obtaining his medical history was difficult. Initial examination was unremarkable, but his condition worsened over several days, with a decline in Glasgow Coma Scale (GCS) and the later development of photophobia, neck stiffness, and a positive Kernig sign. Meningitis was suspected, and cerebrospinal fluid (CSF) analysis ultimately confirmed tuberculous meningitis. Despite treatment, the patient deteriorated further and died. This case highlights how communication barriers can delay diagnosis and the importance of access to medical interpreters, including for rare languages.The case report by internist Priyanta Banerjee and colleagues at Scunthorpe General Hospital in Scunthorpe, England, illustrates how a language barrier in medicine can delay diagnosis and worsen outcomes.The Patient and His Medical HistoryThe patient presented to the emergency department of the hospital in Scunthorpe with fever, general weakness, and reduced oral intake. Taking his medical history was difficult because of a language barrier: His native language was Tetun, and he had very limited English proficiency and only a basic understanding of Portuguese.FindingsUpon admission, the patient’s vital signs were measured. Respiratory and heart rates, blood pressure, and oxygen saturation on room air were within normal ranges. Contrary to the medical history, the patient did not have a fever.Inspection, auscultation, palpation, and percussion revealed no significant findings. The patient was cachectic and weighed only 43 kg (approximately 94 lb), with a height slightly below average.Laboratory results showed leukocytosis at 9.3 × 109/L, elevated C-reactive protein at 14 mg/L, hyponatremia at 122 mmol/L, and hypochloremia at 84 mmol/L.DiagnosisInitial treatment consisted of intravenous fluids and acetaminophen. Starting on the second day of hospitalization, the patient’s condition gradually worsened. By the fourth day, his GCS had dropped from 15/15 to 12/15.A repeat physical and neurologic examination at that time revealed photophobia, neck stiffness, and a positive Kernig sign. Meningitis was clinically diagnosed, and antibiotic therapy with ceftriaxone and acyclovir was initiated. A CT scan of the skull showed no evidence of hydrocephalus or other contraindications for a lumbar puncture.A subsequent lumbar puncture and CSF analysis yielded results consistent with tuberculous meningitis.On the 6th day, the patient’s condition deteriorated. The GCS score had dropped to 6/10. An emergency CT scan revealed new-onset hydrocephalus. No obstructive causes could be identified. An external ventricular drain was placed. Despite being transferred to the intensive care unit, the patient died within 5 days. The body was transferred to the medical examiner’s office, where an autopsy was not performed without documented justification.Discussion“This case highlights the catastrophic consequences of delayed recognition of tuberculous meningitis in an immunocompetent young adult,” the authors of the case report wrote. Robust public health measures and the availability of medical interpreters — including for rare languages — are necessary to prevent such tragedies.This article was translated from Univadis Germany, part of the Medscape Professional Network.