Delayed Diagnosis of Tuberculous Meningitis in an Elderly Male: A Case Report

Abstract:
Background: Tuberculous Meningitis (TBM) remains a significant global health concern, with over 164,000 cases occurring annually worldwide with a mortality rate of approximately 48%. Despite England’s status as a country with low rates of tuberculosis, recent data shows a concerning 11% increase in TB notifications in 2023, with extrapulmonary forms such as TBM presenting particular diagnostic challenges. The diagnosis of TBM in elderly patients presents additional challenges due to atypical presentations and reduced inflammatory responses.
Case Report: We report the case of a male in his early 70s who presented with a 14-day history of severe headache, fever, and constitutional symptoms following recent travel to Pakistan. His initial presentation mimicked viral infection, which contributed to diagnostic delays. The patient subsequently developed communicating hydrocephalus and neurological deterioration, ultimately requiring neurosurgical intervention. Cerebrospinal fluid analysis revealed characteristic findings of TBM with 100% lymphocytes, an elevated protein of 6 g/L (0.15 g/L – 0.4 g/L), and low glucose of 1.4 mmol/L (2.5 mmol/L – 4.4 mmol/L), though TB PCR was initially negative.
Conclusion: This case highlights the diagnostic challenges of TBM in elderly patients, particularly following travel to high-burden countries. Early recognition of risk factors, maintaining high clinical suspicion despite negative molecular tests, and prompt empirical treatment are crucial for improved outcomes in suspected TBM cases.