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The diagnosis of tuberculous meningitis (TBM) is challenging because of the low mycobacterial yield in the CSF and the lack of adequate diagnostic alternatives.1,2 This often places the clinician facing patients with subacute-chronic meningitis in the situation of starting empirical antituberculous therapy while ruling out other etiologies. Adenosine deaminase in the CSF is increased in TBM but has false negatives, and PCR has a less than ideal sensitivity.3 Once anti-mycobacterial therapy is started, some patients with TBM may develop a paradoxical reaction that may give a clue to the correct diagnosis.
In this report we characterize a paradoxical response in a patient with subacute lymphocytic meningitis in whom the microbiologic diagnosis remained elusive for almost 4 weeks.
Case report.
A 70-year-old woman was admitted with a 1-week history of general malaise, disorientation, and fever of 37.7 °C. A cranial CT scan (with and without contrast) was normal, and a spinal tap yielded a mononuclear pleocytosis with increased …
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