1103 - TB or Not TB: Pain and Weakness in Pediatric Disseminated Tuberculosis

Case Diagnosis: PICU-induced Critical Illness Myopathy/Polyneuropathy in the setting of disseminated TB.

Case Description: The patient is a 17-year-old previously healthy female who presented to the ED with acute onset anemia in the setting of four months of unintentional weight loss, fatigue, abdominal pain, and distension. On exam, she had an extended abdomen but no neurological deficits. CT showed a right upper lung cavitary lesion and multiple pulmonary nodules. Gastric aspirate confirmed tuberculosis (TB) diagnosis, antimicrobial therapy was started, and she was admitted to the PICU. Her PICU course was complicated with multidrug-resistant TB, coagulopathy, pulmonary emboli, bacterial peritonitis, encephalopathy, and multiorgan failure. After stabilization, she developed significant diffuse pain and weakness. Her exam demonstrated no spontaneous movement, diminished sensation, and profound neuropathy in the distal extremities. She was hypotonic and areflexic. MRI showed enhancement of the anterior horn nerve roots of the cauda equina. Electrodiagnostic studies showed abnormal, length-dependent severe axonal sensorimotor polyneuropathy leading to a diagnosis of critical illness myopathy/polyneuropathy (CIM/CIP)

Discussions: Pain and weakness in a patient with severe disseminated TB can be multifactorial with a broad differential. There is sparse literature to suggest mycobacterium tuberculosis is a direct cause of peripheral neuropathy. CIM/CIP is a rare phenomenon, reported only to affect less than 1% of PICU admissions. This case demonstrates that a high index of suspicion should be maintained for CIM/CIP in the setting of new-onset polyneuropathy. As physiatrists, it is critical to appropriately evaluate the causes of polyneuropathy and to treat the neuropathy adequately. In our case, the decreased axonal length-dependent polyneuropathy on EMG, combined with her PICU course indicated CIM/CIP rather than TB-related polyneuropathy.

Conclusions: This case highlights complications after initial medical stabilization of critical illness. Comprehensive therapy and supportive care with pain control and complication prevention are standard interventions for CIM/CIP.