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

Abstract

Introduction: Tuberculous meningitis (TBM) remains a major cause of neurological morbidity and mortality, particularly in tuberculosis-endemic regions like India. Tuberculous myelo-arachnoiditis is a rare but serious spinal complication of TBM, reported in approximately 2–5% of cases, often leading to progressive myelopathy and permanent neurological sequelae. Early neuroimaging may be normal, contributing to diagnostic delay.
Case Presentation: A 25-year-old immunocompetent female presented with an 8-day history of progressive headache, followed by fever and altered sensorium. Neurological examination revealed a Glasgow Coma Scale score of E3V3M5, generalized hypotonia, quadriparesis (Medical Research Council grade 2/5 in all limbs), diminished deep tendon reflexes, and bilateral extensor plantars. During hospitalization, she developed a right sixth cranial nerve palsy with progression to quadriparesis. Initial magnetic resonance imaging of the brain was normal. Initial cerebrospinal fluid (CSF) analysis showed mild abnormalities (glucose 52 mg/dL, protein 96 mg/dL, cells 45/mm³ with mixed cellularity). With clinical deterioration, repeat CSF analysis revealed marked hypoglycorrhachia (glucose 23 mg/dL), elevated protein (667 mg/dL), and lymphocytic pleocytosis (110 cells/mm³, 70% lymphocytes). A diagnosis of tuberculous meningitis with tuberculous myelo-arachnoiditis was established. The patient showed rapid clinical improvement following initiation of antitubercular therapy and adjunctive corticosteroids.
Discussion: This case highlights the diagnostic challenges of TBM, including the radiological–clinical dissociation with initially normal neuroimaging, the dynamic evolution of CSF findings, and the importance of recognizing spinal involvement in patients developing progressive motor deficits. The dramatic therapeutic response to antitubercular therapy further supported the diagnosis.
Conclusion: In tuberculosis-endemic regions, TBM should be suspected in patients presenting with subacute meningoencephalitis, even when initial imaging and CSF studies are inconclusive. Early recognition of spinal involvement, serial lumbar punctures, and prompt empirical antitubercular therapy are essential to prevent irreversible neurological disability.