Management of Mycobacterium bovis Meningitis: The Case for Adjunctive Empirical Therapy

Tuberculous meningitis is a devastating manifestation of tuberculosis, disproportionately affecting children and persons with HIV. Despite decades of clinical experience, diagnosis is often delayed and outcomes remain poor. At the US-Mexico border, management is further complicated by the high prevalence of Mycobacterium bovis, a member of the Mycobacterium tuberculosis complex intrinsically resistant to pyrazinamide, one of the few first-line agents with reliable central nervous system penetration. We present a case of M. bovis meningitis in a patient residing near the US-Mexico border, highlighting the diagnostic and therapeutic challenges posed by intrinsic pyrazinamide resistance. Drawing from this case, we review evidence supporting the early use of adjunctive CNS-penetrative antimicrobials during suspected tuberculosis meningitis in regions where M. bovis is endemic.