Atypical Presentation of Tuberculous Meningitis with Early Quadriparesis Due to Tuberculous Myelo-arachnoiditis in a Young Female

Abstract

Abstract
Tuberculous meningitis (TBM) is a severe form of extrapulmonary tuberculosis associated with high morbidity and mortality, particularly in endemic regions. Spinal involvement in TBM, including tuberculous myelo-arachnoiditis, is rare and often underdiagnosed, especially when early neuroimaging is normal. We report the case of a 25-year-old immunocompetent female who presented with subacute meningoencephalitis and subsequently developed progressive quadriparesis and sixth cranial nerve palsy. Initial magnetic resonance imaging and cerebrospinal fluid (CSF) analysis were non-conclusive, leading to diagnostic uncertainty. However, repeat CSF examination revealed marked hypoglycorrhachia, significantly elevated protein levels, and lymphocytic pleocytosis, strongly suggestive of TBM. The patient showed rapid clinical improvement following initiation of antitubercular therapy and corticosteroids. This case highlights the importance of maintaining a high index of clinical suspicion for TBM with spinal involvement, recognizing the dynamic nature of CSF findings, and considering early empirical treatment in tuberculosis-endemic settings to prevent irreversible neurological sequelae.