Serial Polymorphonuclear Predominance of Cerebrospinal Fluid in a Child with Advanced Tuberculous Meningitis: A Case Report

Tuberculous meningitis (TBM) is the most fatal form of tuberculosis. Despite adequate treatment, its mortality and morbidity is high. Clinical, laboratory, and radiologic findings help in diagnosis of TBM, although analysis of cerebrospinal fluid (CFS) might sometimes delay and mislead the rapid diagnosis.
We present a 14- year- old Afghan immigrant male, with uncommon laboratory results of advanced TBM, who referred to Baharloo hospial in Tehran, Iran, in September 2016. He experienced headache and anxiety one month prior to referring to the hospital; he had fever, severe headache, vomiting and showed bizarre behavior 7 days before admission. Suspecting meningoencephalitis, the physician advised empirical treatment. The first CSF revealed polymorphonuclear (PMN) predominance with low glucose, which was repeated in the second and third CSF analysis. This pattern indicates early phase of TB meningitis. In day 4, antituberculous treatment with corticosteroid was administered empirically. Unfortunately, he succumbed to disease in day 36. Polymerase chain reaction (PCR) for mycobacterium tuberculosis (MTB) in CSF was positive. The patient’s presentation (lethargic to coma) and brain computed tomography (CT) scan indicated advanced stage of disease.
All physicians should consider TB meningitis in any patient with low glucose even with serial PMN predominance in CSF.