Delayed diagnosis and treatment in patients with Tuberculous Meningitis

<bold>Background:</bold> Tuberculous meningitis (TBM) is difficult to diagnose due to non-specific symptoms and signs. We aimed to identify what delays in TBM diagnosis and treatment initiation are associated with. Method: We conducted a retrospective study of patients diagnosed with TBM between January 2017 - December 2021 at a London hospital, UK. Radiological and microbiological findings, and the TBM Lancet score were utilised. <bold>Results:</bold> Forty-three patients were included, 19 were migrants and five HIV-positive. Median CSF WCC was 30/mm3 (IQR 141/mm3), lymphocyte 70% (IQR 45%), glucose 2.9mmol/L (IQR 1.6mmol/L) and protein 1353mg/L (IQR 1113mg/L). Median time between presentation and treatment initiation was 10 days (IQR 5-26 days). Median treatment duration was 12 months (IQR 2 months). Two patients were lost to follow up and three died to TB-related causes, all three commenced anti-TB drugs >26 days after initial presentation. All patients had an MRI head. 38/43 (88%) showed findings consistent with TBM. Tuberculomas were most common (63%), followed by meningeal enhancement (60%) and hydrocephalus (16%). Lumbar puncture was performed in all patients and TB culture positive in 12%, PCR in 5% and smear in 2%. Sputum was tested in 51%, and culture positive in 45%, smear 27% and PCR 23%. Extracranial sites were identified in 26 patients through CT chest and abdomen, MRI spine, bronchoscopy, tissue aspiration and biopsy. 10/11 patients who commenced treatment >26 days after initial presentation had extracranial disease sites. <bold>Conclusion:</bold> Delays in TBM diagnosis and treatment initiation are associated with extracranial TB manifestation. Further work is needed to ensure rapid diagnosis and treatment initiation.