A 29-year-old man has 6 weeks of low-grade fever, evening headache, and weight loss. Examination reveals right sixth and seventh cranial nerve palsies with neck stiffness. MRI shows thick basilar meningeal enhancement with hydrocephalus. CSF: lymphocytic pleocytosis 80 cells/uL, protein 180 mg/dL, glucose 2.0 mmol/L (paired serum 6.0). Most likely diagnosis:

• A Partially treated bacterial meningitis
• B Herpes simplex encephalitis
• C Cryptococcal meningitis
• D Tuberculous meningitis ✓

Explanation

Subacute fever with basal meningeal enhancement, lower cranial nerve palsies from basal exudates, hydrocephalus, and CSF showing lymphocytosis, very high protein and low glucose is the textbook picture of tuberculous meningitis in India. Cryptococcus favours immunosuppressed patients with raised opening pressure and usually milder protein rise, HSV causes temporal lobe parenchymal disease rather than basal meningitis, and partially treated bacterial meningitis rarely shows basal enhancement with these nerve palsies.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.