Cerebral tuberculosis in a patient with mixed connective tissue disease (Sharp's syndrome)

History and admission diagnosis: A 57-year-old female patient with fever an d impaired consciousness was admitted to the department of neurology after her first epileptic seizure. She had a 9-year history of mixed connective t issue disease (MCTD, Sharp's syndrome) predominantly presenting with pulmon ary symptoms and destructive arthritis. Endoprothetic surgery had to be per formed several times and she was given long-term immunosuppressive therapy. Investigations: Cerebrospinal fluid analysis showed pleocytosis (59/mm(3)), high protein concentration (2540mg/l) and low glucose level (31 mg/dl) com pared to blood glucose level (122mg/dl) the indicating possible tuberculous meningoencephalitis. Diagnosis, treatment and course: Tuberculostatic therapy was initiated, but despite extensive testing Mycobacterium tuberculosis could initially not b e detected by microscopy, culture or amplification techniques (TMA; transcr iption mediated amplification). Clinical response to antituberculous therap y was poor and the patient developed cerebral ischaemia and hydrocephalus. Because of earlier histological findings from the synovialectomy showing ep itheloid cell granuloma a knee joint specimen from a wound drainage was tes ted and extracerebral tuberculosis was finally confirmed by mycobacterial c ulture so that tuberculosis as the reason for the meningoencephalitis becam e highly probable. Despite slight improvements the patient still had hemipa resis and lethargy as neurological sequalae at: the end of therapy. Conclusion: The case demonstrates the difficulties in the diagnosis of tube rculosis in patients with signs and symptoms similar for those caused by ot her multisystemic diseases. When tuberculous meningitis is considered, ther apy should be initiated even in cases with negative microbiological tests b ecause of severe consequences when treatment: is delayed.