Atypical presentations of tuberculous meningitis--a case report

A case of tuberculous meningitis, proved by cerebrospinal fluid (CSF) cultures, is reported due to atypical findings in CSF. This 19-year-old man developed subacute headache and fever for 2 weeks, followed by focal seizure and left hemiparesis. Initial CSF study showed hemorrhagic lymphocytic pleocytosis with mildly elevated protein and normal sugar content, mimicking viral or postinfectious meningoencephalitis. Follow-up CSF studies showed polymorphonuclear pleocytosis. A concomitant bacterial meningoencephalitis was suspected, though repeated CSF cultures did not isolate any bacteria. The activity of adenosine deaminase in CSF was 12 U/L, highly suggestive of tuberculous meningitis. Magnetic resonance imaging (MRI) showed only a focal meningoencephalitis in the right lateral frontal cortex. Due to progressive deterioration of the clinical status, umbrella therapy, including antimycobacterial drugs and strong antibiotics were given. At a later time, growth of tubercle bacilli was reported in the CSF cultures. Follow-up study of MRI 4 months later, showed thick abnormal enhancement in the basal cisterns and obstructive hydrocephalus, typical findings of chronic basal meningitis.