3/15/22, 12:05 PM Tuberculous Meningitis Differential Diagnoses

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Tuberculous
Meningitis Differential Diagnoses
Updated: Nov 10, 2021
Author: Gaurav Gupta, MD, FAANS, FACS; Chief Editor: Niranjan N Singh, MBBS, MD, DM, FAHS,
FAANEM  more...

DDX

Diagnostic Considerations
Unlike many forms of bacterial meningitis, tuberculous meningitis (TBM) is often difficult to diagnose,
as initial symptoms are generally subacute and often nonspecific (although occasionally may present
more acutely), and neck stiffness is typically not present in the early course of the illness.
[51, 57]  The
duration of presenting symptoms may vary from 1 day to 9 months (on average, 2 weeks), and the
prodrome is usually nonspecific, including headache, vomiting, photophobia, and fever. Meningismus
may also occur. Unlike most of forms of bacterial meningitis, TBM is more likely to cause neurological
deficits, including altered mental status, personality changes, and, as the lesions may result in
neurovascular compression, cranial nerve deficits and infarcts.
[51]  

The clinician should have a high index of clinical suspicion if a patient presents with a clinical picture
of subacute meningitis or encephalitis (particularly if > 5 days) in high-risk groups or in endemic areas.
There is frequently diagnostic uncertainty when differentiating TBM from other meningoencephalitides,
such as partially treated meningitis. TBM must be differentiated not only from other forms of acute and
subacute meningitis but also from conditions such as viral infections and cerebral abscesses. High-
risk groups include patients from endemic areas (eg, from Africa or Asia), those with HIV infection or
alcohol or drug abuse, homeless persons, people in correctional facilities, residents of long-term care
facilities, and malnourished patients.

Diagnostic confusion often exists between TBM and other meningoencephalitides, in particular
partially treated meningitis. Acid-fast bacilli are seen in only approximately 25% of cerebrospinal fluid
(CSF) smears. CSF culture is time-consuming and may not yield positive results. Recent advances
have sought to improve smear sensitivity, such as by nucleic acid amplification tests.
[59]

In one study, 5 features independently predicted the diagnosis of TBM:

Prodromal stage lasting 7 days or longer

Optic atrophy on fundal examination

Focal deficit

Abnormal movements

CSF leukocytes comprising < 50% polymorphonuclear leukocytes

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3/15/22, 12:05 PM Tuberculous Meningitis Differential Diagnoses

Validation of these criteria on another set of 128 patients revealed a sensitivity of 98.4% if at least one
feature was present and a specificity of 98.3% if 3 or more were present. This simple rule is useful for
physicians working in regions where TB is prevalent.

TBM must be differentiated not only from other forms of acute and subacute meningitis but also from
conditions such as viral infections and cerebral abscess. The radiological differential diagnosis, which
should take into account HIV status, includes cryptococcal meningitis, cytomegalovirus encephalitis,
sarcoidosis, meningeal metastases, and lymphoma.

TB of any form is a notifiable disease in the United States. Mandatory notification of the appropriate
health department is the responsibility of the physician who makes the diagnosis.

TBM should be considered in the differential diagnosis in any high-risk patient presenting with fever
and a change in sensorium. Other problems to be considered include:

Infections: Fungal (cryptococcal, histoplasmosis, actinomycetic, nocardiasis, Arachnia infection,

candidiasis, coccidiosis); spirochetal (Lyme disease, syphilis, leptospirosis); bacterial (partially
treated bacterial meningitis, brain abscess, listeriosis, Neisseria species infection, tularemia);
brucellosis; parasitic (cysticercosis, acanthamebiasis, angiostrongylosis, toxoplasmosis,
trypanosomiasis); and viral (herpes, mumps, retrovirus, enterovirus [in
hypogammaglobulinemics])

Acute hemorrhagic leukoencephalopathy

Behçet disease

Chemical meningitis

Chronic benign lymphocytic meningitis

Neoplastic: metastatic, lymphoma

Systemic lupus erythematosus

Vascular: Multiple emboli, subacute bacterial endocarditis, sinus thrombosis

Vasculitis: Isolated central nervous system (CNS) angiitis, systemic giant cell arteritis, Wegener
granulomatosis, polyarteritis nodosa, noninfectious granulomatosis, lymphomatoid
granulomatosis

Vogt-Koyanagi-Harada syndrome

Differential Diagnoses
Acute Disseminated Encephalomyelitis

Acute Subdural Hematoma Management in the ED

Aseptic Meningitis

CNS Cryptococcosis in HIV

Haemophilus Meningitis

Intracranial Epidural Abscess

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Ischemic Stroke

Meningococcal Meningitis

Pediatric Status Epilepticus

SLE vasculitis

Subdural Empyema

Viral Encephalitis

Viral Meningitis

Workup
 

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