Tuberculous Meningitis Complicated by Communicating Hydrocephalus and Lacunar Infarcts: A Case Report

Tuberculous meningitis (TBM) is a life-threatening form of central nervous system tuberculosis (CNS-TB) that often presents with diagnostic and therapeutic challenges, especially in the absence of early microbiological confirmation, and is often associated with complications. We report the case of a previously healthy 32-year-old female who presented with a short history of fever, headache, and altered mental status. Initial cerebrospinal fluid (CSF) analysis revealed a profile consistent with TBM, though microbiological studies were negative. MRI findings showed meningeal enhancement and vasculitic changes. The patient experienced a rapid neurological decline with signs of raised intracranial pressure, necessitating external ventricular drainage and later ventriculoperitoneal (VP) shunting. She also developed hyponatremia likely secondary to syndrome of inappropriate antidiuretic hormone secretion (SIADH), and subsequent imaging revealed multiple lacunar infarcts suggestive of vasculitis-related ischemic injury. CSF culture later confirmed Mycobacterium tuberculosis. The patient responded favorably to empirical anti-tuberculous therapy (ATT), adjunctive corticosteroids, and multidisciplinary supportive care. She made a significant neurological recovery and was discharged ambulant with minimal assistance. This report underscores the importance of early clinical recognition, prompt empirical therapy, and timely neurosurgical intervention in TBM to reduce morbidity, even when initial laboratory confirmation is lacking. Multidisciplinary involvement, and proactive complication management including that which covers hydrocephalus and hyponatremia, are critical to improving outcomes.