Introduction: Diagnosis and management of tuberculous meningitis remain challenging as it is difficult to find the causative agent due to the low sensitivity and delays of the current microbiological techniques. Decisions about when to start antituberculosis therapy remain controversial and often late. The disease commonly presents with nonspecific symptoms at early stages. Consequently, it is recognized only after inflammation at the base of the brain has caused obstructive hydrocephalus, cranial nerve involvement, or vasculitis leading to infarction. When these occur, it is linked to an unfavorable outcome and even death. This study aimed to report case reports of definite and probable tuberculous meningitis and to discuss the need to start an antituberculosis drug.
Case presentation: Description of three case reports and explanation of the literature review. The patient of 11-month-old, 7-month-old, and 5-year-old male infant, presented with a progressive altered level of consciousness, focal to generalized tonic-clonic convulsion, prolonged fever, and history of chronic productive cough. The electrolyte tests all showed hyponatremia. Cerebrospinal fluid (CSF) analysis from the ventricle and lumbar puncture appeared clear, with pleocytosis with mononuclear predominance, raised protein, and reduced glucose. The tuberculosis test using several methods was negative, except for one patient with military tuberculosis and very low MTB detected in cerebrospinal fluid gene X-pert MTB/RIF testing. Head computed tomography (CT) scans with and without contrast showed hydrocephalus, basal meningeal enhancement, and hypodensity in the thalamic region. Patients were evaluated using Lancet criteria which resulted consecutively of two probable tuberculosis and one definite tuberculosis. The first patient was not treated with antituberculosis, the second and third were treated with antituberculosis, but only the third patient survived with a favorable outcome.
Conclusions: The decision to start antituberculosis drug should be promptly initiated in any patient with clinical and CSF findings strongly suggestive of tuberculous meningitis without waiting for bacteriological confirmation, especially in the presence of hyponatremia, hydrocephalus, and abnormal head CT scan consistent with tuberculous meningitis.
Keywords: antituberculosis drug, hydrocephalus, thalamic infarct, tuberculous meningitis