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TB meningitis — SCE Neurology MCQ

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HardCNS InfectionsTB meningitisSCE Neurology

A 45-year-old has 2 weeks of headache, fever, confusion and sixth-nerve palsy. CSF shows lymphocytes, very high protein and low glucose; basal meningeal enhancement and hydrocephalus are present. A rapid molecular test for Mycobacterium tuberculosis is negative, but epidemiology and the remaining findings strongly support tuberculous meningitis. What is the best management?

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Correct answer: A — Start CNS tuberculosis treatment plus high-dose corticosteroid tapered over 4–8 weeks

A negative rapid molecular test does not exclude tuberculous meningitis. NICE advises treating when the clinical and laboratory picture is consistent despite a negative rapid result because delay can be devastating. CNS tuberculosis also warrants adjunctive high-dose dexamethasone or prednisolone with gradual withdrawal over 4–8 weeks. Corticosteroid monotherapy is unsafe, and waiting for slow culture confirmation risks neurological deterioration. Hydrocephalus additionally requires urgent specialist assessment, but it does not replace immediate antituberculous treatment.

Reference: NICE NG33, tuberculosis: https://www.nice.org.uk/guidance/NG33/chapter/Recommendations