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TB Meningitis — RACP Adult Medicine MCQ

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ModerateInfectious DiseasesTB MeningitisRACP Adult Medicine

A 45-year-old woman presents with acute onset severe headache and neck stiffness. She is confused and has a temperature of 39°C. A non-contrast CT brain is normal. LP shows opening pressure 32 cmH₂O, WCC 850 cells/µL (95% lymphocytes), protein 2.2 g/L, and glucose 1.2 mmol/L (serum 5.8 mmol/L). What is the most likely diagnosis?

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Correct answer: A — Tuberculous meningitis

Lymphocytic predominant CSF with markedly elevated protein, very low glucose (CSF:serum ratio <0.3), and elevated opening pressure is the classic CSF profile of tuberculous meningitis. Viral meningitis typically has a normal or mildly reduced glucose and lower protein. Bacterial meningitis is neutrophil-predominant. TB meningitis has the highest mortality of all forms of meningitis and requires immediate treatment with 4-drug anti-TB therapy (HRZE) plus dexamethasone (which reduces mortality – Thwaites trial). Confirm with CSF GeneXpert MTB/RIF.

Reference: eTG – 2025 – Antibiotic Guidelines; NTAC – 2022 – National TB Guidelines