This study aimed to characterize clinical features and outcomes of tuberculous meningitis (TBM) in Thailand, and to identify factors associated with poor clinical outcomes, delayed presentation, and treatment initiation.

TBM remains the most severe manifestation of tuberculosis, particularly in people living with HIV (PLWH).

We retrospectively identified adults with suspected TBM at King Chulalongkorn Memorial Hospital (KCMH), Bangkok, Thailand, between 2012 and 2025. Detailed chart review was conducted. TBM was categorized as definite, probable, and possible, according to the consensus uniform case definition. Modified Rankin Scale (mRS) was assessed at discharge and 1-year follow-up. Multivariable logistic regression was used to evaluate factors associated with poor clinical outcomes, delayed presentation, and treatment initiation.

Among 113 patients identified, 32.7% met criteria for definite TBM, 23.0% probable, and 44.2% possible. Median age was 43 (IQR 30–55) years; 25.7% were female and 39.8% had HIV. Common presenting symptoms included fever (80.5%), headache (62.8%), and altered mental status (55.8%). CSF analysis showed elevated opening pressure in 40.7%, CSF-to-serum glucose ratio 0.3 (0.2–0.4), and positive definitive TB diagnostic testing in less than one-third. At discharge, 47.8% had poor outcomes (mRS>2), including mortality of 10.6%. BMRC grade II (adjusted odds ratio [aOR] 8.07; 95%CI, 2.46–32.93) and BMRC grade III (aOR 38.39; 95%CI, 6.17–366) were associated with worse outcomes at discharge. Higher baseline serum albumin levels were associated with reduced odds of poor outcomes (aOR 0.3; 95%CI, 0.12–0.67). Prolonged cough (aOR 0.15; 95%CI, 0.04-0.46) and BMRC grade II (aOR 0.37; 95%CI, 0.13-0.96) were associated with delayed presentation to the hospital. A normal CSF-to-serum glucose ratio (aOR 0.12; 95%CI, 0.01-0.8) was associated with delayed treatment.

TBM in Thailand commonly presents with fever, headache, and altered mental status, with baseline clinical features predicting short-term outcomes, highlighting the importance of early diagnosis and timely treatment to improve prognosis in TBM.