Abstract
Introduction: tuberculous meningitis is the most severe form of extrapulmonary tuberculosis, with mortality rates approaching 50%. Neurological damage is primarily driven by dysregulated host neuroinflammatory responses following the invasion of the central nervous system by Mycobacterium tuberculosis.
Case report: A case is presented of a 45-year-old male, a former inmate, with a one-month clinical course characterized by constitutional symptoms, headache, and progressive neurological impairment. Physical examination revealed meningeal syndrome and sixth cranial nerve palsy. Cerebrospinal fluid analysis showed lymphocytic pleocytosis (410 cells/mm³, 88% lymphocytes), hyperproteinorrachia (260 mg/dL), and hypoglycorrachia (18 mg/dL). The diagnosis was confirmed via GeneXpert and neuroimaging, which evidenced basal leptomeningeal enhancement and hydrocephalus. Treatment was initiated with the HRZE regimen and adjuvant dexamethasone, achieving significant clinical improvement after 35 days of hospitalization. Discharge was coordinated to complete the total planned duration of antituberculous treatment through the Directly Observed Treatment, Short-course (DOTS/TAES) program. At the time of discharge, the patient was oriented and able to walk with minimal assistance, with the sixth cranial nerve palsy showing signs of progressive improvement.
Conclusions: early diagnosis based on epidemiological and clinical suspicion is vital. Timely management with antitubercular drugs and corticosteroids significantly reduces mortality and permanent sequelae.
References
1. Donovan J, Figaji A, Imran D, Phu NH, Rohlwink U, Thwaites GE. The neurocritical care of tuberculous meningitis. Lancet Neurol. 2019;18(8):771-83. doi:10.1016/S1474-4422(19)30154-1
2. Huynh J, Donovan J, Phu NH, Nghia HDT, Thuong NTT, Thwaites GE. Tuberculous meningitis: progress and remaining questions. Lancet Neurol. 2022;21(5):450-64. doi:10.1016/S1474-4422(21)00435-X
3. Walusinski O. History of the Concept of Tuberculous Meningitis. Eur Neurol. 2021;84(1):61-70. doi:10.1159/000512468
4. Donovan J, Cresswell FV, Tucker EW, Davis AG, Rohlwink UK, Huynh J, et al. A clinical practice guideline for tuberculous meningitis. Lancet Infect Dis. 2026;26(2):e96-111. doi:10.1016/S1473-3099(25)00364-0
5. Navarro-Flores A, Fernandez-Chinguel JE, Pacheco-Barrios N, Soriano-Moreno DR, Pacheco-Barrios K. Global morbidity and mortality of central nervous system tuberculosis: a systematic review and meta-analysis. J Neurol. 2022;269(7):3482-94. doi:10.1007/s00415-022-11052-8
6. Jullien S, Ryan H, Modi M, Bhatia R. Six months therapy for tuberculous meningitis. Cochrane Infectious Diseases Group, editor. Cochrane Database Syst Rev. 2016;2017(9). doi:10.1002/14651858.CD012091.pub2
7. Seid G, Alemu A, Dagne B, Gamtesa DF. Microbiological diagnosis and mortality of tuberculosis meningitis: Systematic review and meta-analysis. Osman M, editor. PLOS ONE. 2023;18(2):e0279203. doi:10.1371/journal.pone.0279203
8. Kamarulzaman A, Reid SE, Schwitters A, Wiessing L, El-Bassel N, Dolan K, et al. Prevention of transmission of HIV, hepatitis B virus, hepatitis C virus, and tuberculosis in prisoners. The Lancet. 2016;388(10049):1115-26. doi:10.1016/S0140-6736(16)30769-3
9. Herrera M, Keynan Y, López L, Marín D, Arroyave L, Arbeláez MP, et al. Incidence and Risk Factors Associated with Latent Tuberculosis Infection and Pulmonary Tuberculosis among People Deprived of Liberty in Colombian Prisons. Am J Trop Med Hyg. 2022;106(1):66-74. doi:10.4269/ajtmh.20-0307
10. Hernandez AV, De Laurentis L, Souza I, Pessanha M, Thota P, Roman YM, et al. Diagnostic accuracy of Xpert MTB/RIF for tuberculous meningitis: systematic review and meta‐analysis. Trop Med Int Health. 2021;26(2):122-32. doi:10.1111/tmi.13525
11. Kohli M, Inbaraj LR, Salomon A, Scandrett K, Korobitsyn A, Ismail N, et al. Low-complexity automated nucleic acid amplification tests for extrapulmonary tuberculosis and rifampicin resistance in adults and adolescents. Cochrane Central Editorial Service, editor. Cochrane Database Syst Rev. 2025;2025(8). doi:10.1002/14651858.CD012768.pub4
12. Horne DJ, Zifodya JS, Shapiro AE, Church EC, Kreniske JS, Kay AW, et al. Xpert MTB/RIF Ultra assay for pulmonary tuberculosis and rifampicin resistance in adults and adolescents. Cochrane Database Syst Rev. 2025;(7). doi:10.1002/14651858.CD009593.pub6
13. Nahid P, Dorman SE, Alipanah N, Barry PM, Brozek JL, Cattamanchi A, et al. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis. 2016;63(7):e147-95. doi:10.1093/cid/ciw376
14. Thwaites GE, Chau TTH, Stepniewska K, Phu NH, Chuong LV, Sinh DX, et al. Diagnosis of adult tuberculous meningitis by use of clinical and laboratory features. Lancet. 2002;360(9342):1287-92. doi:10.1016/s0140-6736(02)11318-3 PubMed PMID: 12414204.
15. Misra UK, Kalita J, Kumar M, Tripathi A, Mishra P. Complications of tuberculous meningitis and their effect on outcome in a tertiary care cohort. Int J Tuberc Lung Dis. 2020;24(11):1194-9. doi:10.5588/ijtld.20.0036
16. Thwaites GE, Van Toorn R, Schoeman J. Tuberculous meningitis: more questions, still too few answers. Lancet Neurol. 2013;12(10):999-1010. doi:10.1016/S1474-4422(13)70168-6
17. Igbokwe V, Ruby LC, Sultanli A, Bélard S. Post-tuberculosis sequelae in children and adolescents: a systematic review. Lancet Infect Dis. 2023;23(4):e138-50. doi:10.1016/S1473-3099(23)00004-X
18. Kamarulzaman A, Reid SE, Schwitters A, Wiessing L, El-Bassel N, Dolan K, et al. Prevention of transmission of HIV, hepatitis B virus, hepatitis C virus, and tuberculosis in prisoners. Lancet. 2016;388(10049):1115-26. doi:10.1016/S0140-6736(16)30769-3 PubMed PMID: 27427456.
This work is licensed under a Creative Commons Attribution 4.0 International License.
Copyright (c) 2026 Maikro Osvaldo Chávez Moya, Gabriela González Pernas, Elizabeth Soler Ruiz, Dashiell González Abreu, Leodanis Hernández Cabrera, Orlando Jesús Espinosa Romero, Neisy Pérez Ramos (Author)