Atypical manifestations of tuberculous meningitis

We describe 2 patients with tuberculous meningitis who exhibited unusual changes of their cerebrospinal fluid (CSF) which led to confusion in their management. Patient 1 was a 25-year-old man who displayed persistent polymorphonuclear dominant pleocytosis in his CSF. Autopsy revealed marked hypoplasia of the thymus and T cell areas of the lymph nodes, consistent with the Nezelof syndrome, as well as disseminated tuberculosis. Patient 2 was a 39-year-old woman who demonstrated, during appropriate antituberculous chemotherapy, an atypical exacerbation consisting of prolonged fever, polymorphonuclear dominant pleocytosis in her CSF and multiple cerebral infarcts. The neurological abnormalities in the patient underwent marked improvement following oral prednisolone therapy.