Acute Psychosis as Clinical Manifestation of Tuberculous Meningitis

A young female was admitted with complaint of low grade fever, loss of appetite and fluctuating behaviour from the past two week. There was no history of any seizures, loss of consciousness, tuberculosis or any psychiatric illness. On examination the patient was apathetic, drowsy and her Glasgow Coma Scale was 13/15(E4V3M6). The patient was bed ridden and most of the time she use to sleep with occasional interruptions by episodes of agitation. No bladder bowel involvement was present. Motor system examination revealed grade 4/5 power in all four limbs with normal muscle tone and bilateral plantar flexor response. There was no signs of meningeal irritation (neck rigidity, Kernig’s and Brudzinski’s sign).

All routine investigation including CSF and CT scan was normal. On clinical ground she was diagnosed as a case of acute psychosis and kept on olanzapine. Initially she responded to drug, but again she was admitted due to headache, nausea and instability of gait. Cerebrospinal fluid examination was suggestive of tuberculous meningitis. MRI of brain showed infarct in right cerebellar hemisphere. The patient was treated with anti-tubercular drugs and steroids. On follow-up visit one month later, her psychotic symptoms had fully resolved. She was able to ambulate and care for herself.