Tuberculous Meningitis (TBM) is a challenging entity to diagnose as well as to treat. Most of the treatment principles are based on data from pulmonary Tuberculosis (TB). The Fixed Dose Combination (FDC) formulation is currently recommended for the treatment of active TB. The goal of FDC tablets is to simplify TB therapy and facilitate compliance. This strategy has been proven effective in pulmonary TB. However, is this strategy appropriate for a fulminant condition such as TBM?

22-year-old patient presented with high fever and a severe headache for ten days with a two-day history of an altered sensorium. Examination revealed features of meningism with no focal neurological signs. CSF studies showed a lymphocytic pleocytosis with elevated proteins and a severe sugar drop. After a poor response to intravenous (IV) antibiotics, a clinical diagnosis of TB meningitis was made. Treatment with Isoniazid, Rifampicin, Pyrazinamide and Ethambutol was started in a fixed dose formula with oral steroid cover. Despite treatment with the above regimen, she continued to deteriorate with a fluctuating level of consciousness and a visual field defect. CT brain revealed a communicating hydrocephalus with an infarct in the right temporal-occipital region.

The treatment was changed to administer the individual drugs separately with the dose tailored to the patients’ weight. Steroids were converted to IV Dexamthasone. This regimen was continued for two months following which she made a steady recovery. In total, the intensive phase of treatment was given for 14 weeks while corticosteroids in the intravenous form was given 6 weeks. She is currently on the continuation phase of ATT. Additional anti tuberculous agents were not used. Her CSF culture was found to be positive for Mycobacterium Tuberculosis.