Images in Clinical Medicine
Tuberculous Meningitis
N Engl J Med 1999; 341:1197October 14, 1999
- Article
Figure 1 A 62-year-old previously healthy woman was admitted with a three-week history of fever, fatigue, night sweats, headache, and vomiting and a two-month history of progressive weight loss. She reported memory loss, poor concentration, and insomnia. On neurologic examination, she was confused and answered questions slowly but had no stiffness of the neck, cranial-nerve palsies, or pyramidal signs. Cerebrospinal fluid analysis revealed pleocytosis (340 white cells per cubic millimeter, 80 percent lymphocytes), elevated protein levels (2.4 g per liter), and low glucose levels (38 mg per deciliter [2.1 mmol per liter]). A plain film and a computed tomographic scan of the chest were normal. Contrast-enhanced T1-weighted axial magnetic resonance imaging showed diffuse, thick, and sometimes nodular enhancement of the basal meninges (arrows), presumably due to inflammation. These findings are highly suggestive of tuberculous meningitis but may also be observed in patients with sarcoidosis, Wegener's granulomatosis, fungal meningitis, or chronic meningitis due to nocardia or actinomyces. Acid-fast bacilli were not seen on Ziehl–Neelsen staining of cerebrospinal fluid, but Mycobacterium tuberculosis grew in a culture of cerebrospinal fluid after four weeks, confirming the diagnosis of tuberculous meningitis. The patient was treated with ethambutol, pyrazinamide, isoniazid, rifampin, and corticosteroids and was asymptomatic one month later. Meningeal lesions had disappeared on magnetic resonance images obtained three months later.
Jean-François Viallard, M.D.
Patrick Blanco, M.D.
Haut-Lévêque Hospital, Bordeaux, France
