Synopsis
Recognise subacute tuberculous meningitis, obtain high-volume cerebrospinal-fluid microbiology without trusting a negative rapid assay, start multidrug treatment and corticosteroids promptly, and manage hydrocephalus, infarction and paradoxical inflammation.
- TB meningitis usually evolves over days to weeks with headache, fever, malaise, weight loss, cranial neuropathy or cognitive decline.
- CSF commonly shows lymphocytes, high protein and low glucose, but early neutrophils and immune-suppressed low-cell profiles occur.
- Send a large CSF volume for mycobacterial culture and molecular testing and repeat sampling when initial tests are negative but probability remains high.
Key red flags
Reduced consciousness, papilloedema, repeated vomiting or sixth-nerve palsy raises hydrocephalus and requires urgent neuroimaging and neurosurgical review.
Weeks of headache, fever, vomiting, lethargy and weight loss with neck stiffness or cranial neuropathy is a typical presentation.
Investigation priorities
Maximise smear, culture and molecular diagnostic yield.
Management branches
Subacute meningitis with low glucose, cranial neuropathy or TB exposure creates significant probability.
- Stabilise physiology, examine cranial nerves and focal neurology and obtain urgent imaging before lumbar puncture when mass effect is plausible.
- Collect high-volume CSF and multiple extraneural specimens for molecular tests, culture and susceptibility before therapy when safe.
Key medicines
Initial TB meningitis regimenGive weight-banded rifampicin, isoniazid, pyrazinamide and ethambutol daily for 2 months under current NICE and TB-service guidance.
Continuation TB meningitis regimenContinue weight-banded rifampicin and isoniazid daily for about 10 further months when drug-susceptible disease is confirmed.