Miliary Tuberculosis Presenting With Meningitis in a Patient Treated With Mycophenolate for Lupus Nephritis: Challenges in Diagnosis and Review of the Literature.

Tuberculosis is one of the top 10 causes of death worldwide according to the World Health Organization. Central nervous system involvement is usually the least common presentation of tuberculosis occurring in about 1% of all cases but yet can have very devastating outcomes. Lupus nephritis is one of the most common complications of systemic lupus erythematosus with up to two thirds of patients presenting with some degree of renal dysfunction. The mainstay of treatment is glucocorticoids; however, to sustain remission, steroid sparing agents such as cyclophosphamide, azathioprine and mycophenolate mofetil are used. Such patients, in addition to their baseline dysfunctional immune system, have a heightened risk of infections due to these drugs. In this article, we present a young woman who had recently been started on mycophenolate mofetil for control of class V lupus nephritis who presented with headaches, sinus pressure, and fevers. She had a protracted course of hospitalization as she failed to improve clinically and to respond to conventional therapy for acute bacterial sinusitis and meningitis. She was empirically started on antitubercular therapy 9 days after hospitalization. The diagnosis was not confirmed until day 18, the day results of cerebrospinal fluid acid-fast bacillus culture was reported. This case is reported to highlight the challenges in diagnosing Mycobacterium tuberculosis infection in an immunocompromised state and to demonstrate that its presentation can mimic numerous other conditions. Clinicians must maintain a high index of suspicion of Mycobacterium tuberculosis infection in such patients who present with nonspecific or unexplainable symptoms.

"What's in a name?" Delirium by any other name would be as deadly. A review of the nature of delirium consultations.

INTRODUCTION: Delirium is often underdiagnosed, resulting in adverse clinical outcomes. The goal of this study was to identify how patients correctly diagnosed with delirium differ from those who are misdiagnosed. METHODS: A retrospective chart review was conducted using a database of 1,000 consecutive psychiatric consultation requests. Patients were identified based on a diagnosis of delirium made by the consultation team. Charts were then reviewed for data on race, gender, age, time and month of the consultation, documented diagnosis of mental illness, and information that would help establish a delirium diagnosis based on DSM-IV-TR criteria. Univariate and multivariate analyses were performed. RESULTS: Cases were judged to be diagnostically concordant (consultation requested for delirium or encephalopathy, n = 30) or discordant (n = 81). The two groups did not differ significantly in age, sex, race, time and month of the consultation, or documentation of mental illness. The concordant group had a significantly greater number of identifiable diagnostic criteria compared to the discordant group (mean 3.0 ± 0.8 criteria vs. 1.9 ± 1.3 criteria, P < 0.001). Identification of individual diagnostic criteria was greater in the concordant group, with significant differences for two of four categories, namely acute onset (100.0% vs. 50.6%, P < 0.001) and fluctuating course (93.3% vs. 66.7%, P = 0.004). Multivariate analysis suggested increased odds of identifying delirium if more diagnostic criteria were identifiable (OR: 2.355, P < 0.001, confidence interval [CI] 1.502-3.690), and increased likelihood of the delirium diagnosis being missed if there was documentation of psychiatric illness (OR: 0.387, P = 0.049, CI: 0.151-0.995). CONCLUSION: This study highlights the need for educational programs and easy to implement screening tools to ensure delirium is not overlooked.