Tuberculous Meningitis with Longitudinally Extensive Transverse Myelitis: A Rare Case Report

Abstract

Introduction: Tuberculous meningitis (TBM) is a severe form of central nervous system tuberculosis. Longitudinally extensive transverse myelitis (LETM), involving ≥3 vertebral segments, is a rare spinal complication. Their coexistence is exceptionally uncommon and can cause severe neurological deficits.

Aim & Objective: To highlight the rare association of TBM with LETM and emphasize the importance of early diagnosis through clinical assessment, cerebrospinal fluid (CSF) analysis, microbiological confirmation, and magnetic resonance imaging (MRI).

Case Presentation: A 20-year-old female presented with fever for 20 days, urinary retention for 14 days, headache and gait difficulty for 3 days, and altered sensorium for 1 day. Examination revealed decreased higher mental functions, positive Kernig’s and Brudzinski’s signs, upper-limb power of 4/5, lower-limb power of 0/5, and absent reflexes. CSF showed 30 cells/mm³ with 90% lymphocytes, protein 608 mg/dL, glucose 15.7 mg/dL, raised ADA, and CBNAAT positivity for Mycobacterium tuberculosis. Spinal MRI demonstrated heterogeneous signal alteration and enhancement from C7 to D5, consistent with LETM. Brain MRI showed enhancing lesions in the interpeduncular and perimesencephalic cisterns and bilateral parietal sulci.

Result: Anti-tubercular therapy, physiotherapy, bladder management, intravenous methylprednisolone (30 mg/kg/day), and oral corticosteroids were administered. Fever and sensorium improved within 5 days, with marked neurological recovery within 2 weeks.

Conclusion: TBM-associated LETM should be considered in patients presenting with meningitic features and acute myelopathy. Early combined anti-tubercular and corticosteroid therapy may promote favorable neurological recovery and prevent irreversible disability.

REFERENCES

1. Zhang M, Tian Y, Gao B, Qin X, Shen Q, Li Z, et al. Interpretation of the Global Tuberculosis Report 2025: global epidemic trends and China’s control strategy. Zoonoses. 2026;6(1):1-25. https://doi.org/10.15212/zoonoses-2026-0002
2. Donovan J, Cresswell FV, Tucker EW, Davis AG, Rohlwink UK, Huynh J, et al. A clinical practice guideline for tuberculous meningitis. Lancet Infect Dis. 2026;26(2):96-111.
3. Oo N, Agrawal DK. Epidemiology, pathogenesis, clinical manifestations, and management strategies of tuberculous meningitis. Arch Intern Med Res. 2025;8(1):48-58. https://doi.org/10.26502/aimr.0195
4. Garg D, Radhakrishnan DM, Agrawal U, Vanjare HA, Gandham EJ, Manesh A. Tuberculosis of the spinal cord. Ann Indian Acad Neurol. 2022;26(2):1-15. https://doi.org/10.4103/aian.aian_578_22
5. Salari M, Zaker Harofte B, Etemadifar M. Longitudinal extensive transverse myelitis due to tuberculosis: a case report. Neuroradiol J. 2023;36(2):224-228. https://doi.org/10.1177/19714009221122188
6. Tian S, Dong N, Li M, Yadav S, Cheng S, Wang B, et al. Tuberculous longitudinal extensive transverse myelitis: 2 cases and literature review. J Spinal Cord Med. 2025;48(2):189-198. https://doi.org/10.1080/10790268.2024.2426315
7. Mohmed MHA, Idrees IHD, Mostafa A, Ibrahim KEM, Ahmad AA, Daoud MH. A case report of long-segment tuberculous myelitis with concomitant tuberculous meningitis. AME Case Rep. 2025;9:1-6. https://doi.org/10.21037/acr-24-211
8. Anand KA, Bhowmik KK, Sarkar A, Ghosh R, Mandal A, Swaika B, et al. Tubercular longitudinally extensive transverse myelitis (LETM): an enigma for primary care physicians. J Family Med Prim Care. 2021;10(2):1-4. https://doi.org/10.4103/jfmpc.jfmpc_2101_20
9. Sahu S, Giri S, Gupta N. Longitudinal extensive transverse myelitis due to tuberculosis: a report of four cases. J Postgrad Med. 2014;60(4):409-412. https://doi.org/10.4103/0022-3859.143977
10. Jain RS, Kumar S, Tejwani S. A rare association of tuberculous longitudinally extensive transverse myelitis (LETM) with brain tuberculoma. Springerplus. 2015;4(1):1-5. https://doi.org/10.1186/s40064-015-1232-z
11. Kasundra GM, Sood I, Bhushan B, Bhargava AN, Shubhkaran K. Distal cord-predominant longitudinally extensive myelitis with diffuse spinal meningitis and dural abscesses due to occult tuberculosis: a rare occurrence. J Pediatr Neurosci. 2016;11(1):77-79. https://doi.org/10.4103/1817-1745.181268
12. Liu X, Rui M, Lyu L. Tuberculous meningomyelitis in magnetic resonance imaging: a Chinese case report. Eur J Radiol Open. 2019;6:284-286. https://doi.org/10.1016/j.ejro.2019.02.006
13. Noh MSFM, Bahari N, Rashid AMA. Tuberculous myelopathy associated with longitudinally extensive lesion: a clinicoradiological review of reported cases. J Clin Neurol. 2020;16(3):1-7. https://doi.org/10.3988/jcn.2020.16.3.369
14. Zafar Z, Hafeez MH, Butt MURA. Elusive tuberculous meningitis with rare neurological complication of longitudinally extensive transverse myelitis: a case report. Spinal Cord Ser Cases. 2021;7(1):1-10. https://doi.org/10.1038/s41394-021-00445-y
15. Khan MI, Garg RK, Rizvi I, Malhotra HS, Kumar N, Jain A, et al. Tuberculous myelitis: a prospective follow-up study. Neurol Sci. 2022;43(9):5615-5624. https://doi.org/10.1007/s10072-022-06221-6
16. Jiang Y, Xu X, Guo Z, Liu Y, Lin J, Suo L, et al. Myelitis: a common complication of tuberculous meningitis predicting poor outcome. Front Neurol. 2022;13:1-11. https://doi.org/10.3389/fneur.2022.830029
17. Garg RK, Kumar N, Uniyal R, Sharma PK, Malhotra HS, Rizvi I. Tuberculous myelitis: a systematic review of published case reports and case series. Spinal Cord Ser Cases. 2025;11(1):1-6. https://doi.org/10.1038/s41394-025-00701-5