Delirium as primary manifestation of a tuberculous meningoencephalitis

This case report emphasizes the importance of central nervous system infect ions for the differential diagnosis of psychiatric symptoms. We report on a patient with progressive depressive symptoms culminating in delirium. The results of cerebrospinal fluid examination (lymphomonocytic pleocytosis wit h markedly increased protein and reduced glucose quotient) and magnetic res onance imaging (pronounced enhancement of the basal leptomeninges, diffuse brain oedema, and marked hydrocephalus) suggested a diagnosis of neurotuber culosis. An extensive search for an infectious agent was negative, apart fr om a weakly positive polymerase chain reaction indicating tuberculi in the cerebrospinal fluid. Upon treatment with combination anti-tuberculous thera py, the cerebrospinal fluid and magnetic resonance imaging abnormalities re solved and the patient's psychiatric and neurologic symptoms dissipated. Th e patient's clinical course and the exclusion of other etiologies support t he diagnosis of tuberculous meningoencephalitis. This case report illustrat es the occurrence of the often poorly described psychopatilological changes as the presenting manifestations of tuberculous meningoencephalitis and th e importance of initiating empiric anti-tuberculous therapy if tuberculosis is suspected, whereas cultures for tuberculosis remain negative.