An Unusual Presentation of Spinal Tuberculosis Masquerading as Pyogenic Meningitis: A Case Report

Background Spinal tuberculosis (TB), though accounting for up to 50% of skeletal TB cases, typically presents insidiously with back pain, kyphotic deformity, or neurological deficits. Atypical presentations, including initial neutrophilic pleocytosis in cerebrospinal fluid (CSF), can mimic bacterial meningitis and complicate diagnosis. Case presentation We report the case of a 46-year-old previously healthy male who initially presented with high-grade fever, headache, neck stiffness, and neutrophilic CSF pleocytosis suggestive of bacterial meningitis. Despite empirical antibiotic therapy, the patient developed progressive neurological symptoms, including paraplegia and hypertonia. MRI of the spine revealed T2-T6 vertebral body involvement with compressive myelopathy consistent with spinal TB. CSF PCR for Mycobacterium tuberculosis was positive. Anti-TB therapy and adjunct corticosteroids were initiated, leading to marked clinical improvement. Conclusion Clinicians should maintain a high index of suspicion for spinal TB in patients with persistent fever, neurological symptoms, and CSF pleocytosis-especially in TB-endemic regions-even when initial laboratory findings suggest bacterial meningitis. Early imaging and targeted therapy can significantly improve outcomes.