Tuberculous Meningitis in a Young Adolescent: A Diagnostic Conundrum

The occurrence of tuberculous meningitis in children is relatively rare, but it is associated with higher rates of mortality and severe morbidity. Confirmation of diagnosis is often difficult, and other infectious aetiologies such as bacterial, viral and fungal causes must be ruled out. We present a ten year old boy who presented on account of fever, convulsion, inability to sit or stand without support and unresponsiveness. Pertinent examination findings were: asthenia in a young adolescent, altered sensorium, reactive pupils, neck stiffness, absent Kernig’s and Brudzinski’s signs with diminished deep tendon reflexes bilaterally. Initial working diagnosis was cerebral malaria (keeping in view pyogenic meningitis). Cerebrospinal fluid (CSF) analysis showed turbid CSF appearance with markedly elevated protein. CSF culture yielded growth of Neisseria menigitidis. Child was commenced on intravenous antibiotic (a third generation cephalosporin with good blood brain barrier penetrating ability). There was no remarkable clinical improvement in the first week of admission necessitating neuroimaging. Cranial computed tomography scan and brain magnetic resonance imaging showed dilatation of all the ventricular cisterns. Tuberculous meningitis complicated by hydrocephalus was then considered and antitubercular regimen commenced. Ventriculoperitoneal shunt (for CSF diversion) was inserted. He spent three months on admission. He, however, did not make full neurologic recovery. Physiotherapy (commenced during admission) was continued on outpatient basis. Child passed on at home three months following hospital discharge. Tuberculous meningitis remains a fatal and a highly disabling disease in children. Prevention will play a crucial role stemming the tide of this deadly disease.