A 5-year-old presents with 5 days of fever, severe headache, photophobia, and neck stiffness. CSF analysis: WBC 1200/mm3 (95% lymphocytes), glucose 25 mg/dL (blood glucose 90 mg/dL), protein 180 mg/dL. Gram stain negative. Which diagnosis and empirical treatment is appropriate while awaiting further investigations?

• A Bacterial meningitis — ceftriaxone + dexamethasone
• B Viral (aseptic) meningitis — symptomatic treatment; antibiotics not needed
• C Viral encephalitis (HSV) — acyclovir empirically
• D Tuberculous meningitis — anti-TB therapy (HRZE) + dexamethasone ✓

Explanation

Tuberculous meningitis (TBM) characteristically presents with: subacute onset (days–weeks), lymphocytic pleocytosis (lymphocyte predominance), markedly low CSF glucose (CSF glucose <45 mg/dL, CSF:blood glucose ratio <0.5), elevated protein (often >200 mg/dL), and negative gram stain. The prolonged fever (5 days), subacute course, and this CSF profile (predominantly lymphocytes, very low glucose, high protein, gram-stain negative) are strongly suggestive of TBM. Empirical anti-TB therapy (HRZE for 2 months, then HR for 7–10 months) plus adjuvant dexamethasone (which reduces mortality and neurological sequelae) should be started without delay pending confirmatory tests (CSF AFB, culture, GeneXpert). Bacterial meningitis typically has PMN predominance.

Reference: Ghai Essential Pediatrics, 10th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.