2025, Vol. 7, Issue 3, Part C

Tuberculous meningitis (TBM) remains a diagnostic challenge due to its non-specific presentation, low sensitivity of microbiological tests, and the frequent masking effect of steroids and antibiotics. We present the case of a 62-year-old male with a one-month history of intermittent fever, initially treated elsewhere as bilateral pyelonephritis with antibiotics and steroids but without improvement. Upon referral to our center, PET scan, Mantoux test, and interferon gamma release assay (IGRA) were negative, and routine investigations were largely unremarkable. However, after tapering steroids, fever recurred with hyponatremia due to syndrome of inappropriate antidiuretic hormone secretion (SIADH). MRI brain with contrast demonstrated meningeal enhancement and acute pontine infarct, while cerebrospinal fluid (CSF) analysis showed high protein and low glucose consistent with TBM, despite negative microbiological assays. Clinical judgment, supported by imaging, guided initiation of anti-tubercular therapy (ATT), resulting in symptomatic improvement. This case emphasizes the limitations of relying solely on laboratory tests in TBM and underscores the importance of clinical acumen and multidisciplinary management.