The Challenges of Diagnosing Tuberculous Meningitis and Importance of Early Intervention

Reported is a patient found to have miliary TB seeding the lungs and brain with CNS involvement resulting in tuberculous meningitis (TBM). False security in laboratory studies that lack adequate sensitivity resulted in delay of therapy which may have negatively impacted the patient's outcome. This case report aims to emphasize the importance of early initiation of therapy when clinical suspicion remains high despite initially negative diagnostic studies.

52 year old female originally from Guatemala presented headache, neck pain, vomiting and photophobia. CT of the chest showed numerous submillimeter sized bilateral lung nodules, with scattered calcifications. IGRA of the serum, sputum Acid Fast Bacillus (AFB) stain and culture and CSF AFB stain and culture were obtained and were all initially negative. Clinical suspicion for tuberculous meningitis remained high and RIPE therapy and methylprednisolone were started. CSF AFB culture was found positive for MTB. Despite therapy, patient continued to clinically decline with poor overall prognosis.

Early diagnosis and initiation of therapy is paramount in improving outcomes in TBM. Unfortunately, the available diagnostic tests lack adequate sensitivity to confidently rule out disease. False negative results can delay therapy and worsen clinical outcomes. Early identification often relies on history, evaluation of risk factors, in conjunction with corresponding labs and imaging findings. If clinical suspicion is high, empiric therapy should be initiated early. Infectious disease consultation is often indicated to further assist with diagnosis and management.