Tuberculous meningitis: diagnostic and management pitfalls

The diagnosis of tuberculous meningitis (TBM) demands a high index of suspicion. The prognosis depends on the stage of the disease the diagnosis is made and how early the treatment is instituted. The outcome of the disease is very poor when the diagnosis and treatment are late. This is what happened to this child, a 7-year-old Malay girl who presented at stage III TBM. The diagnosis was confirmed by a positive culture of M. tuberculosis from the cerebrospinal fluid (CSF). The delay in the diagnosis in this child had catastrophic consequences. She had hydrocephalus at presentationhowever ventricular drainage was not done because parental consent was not obtained. She was started on acetazolamide and frusemide, and daily lumbar puncture in an attempt to reduce the raised intracranial pressure (ICP) in addition to anti-tuberculous chemotherapy. However when she showed no improvement, an external lumbar drain was inserted. The CSF was checked daily and the level of protein and glucose became normal after 6 weeks. The CT scan showed improvement of the hydrocephalus. However, the girl remained severely disabled after treatment and had to be fed via nasogastric tube and needed constant nursing care