Ref Number = PITIKA-ASPR0171
Patricia Yulita Gunawan
Background: Indonesia is one of the top 5 countries with highest incidence of tuberculosis in the world. Tuberculous meningitis is the most severe complication of tuberculosis and frequently occurs in childhood, with high morbidity and mortality rates. The classic symptoms of meningitis, which are fever, headache and neck stiffness, can be variable or absent in young children. We present a case of pediatric tuberculous meningitis with nonspecific presentation. 
Case: A 14-years-old boy presented with main complaint of headache which had been felt intermittently for approximately a month, but had become more frequent since 3 days ago. The patient was fully alert with normal vital signs, positive meningeal signs and increased physiological reflexes. The laboratory result showed slightly elevated erythrocyte sedimentation rate, slight hyponatremia and slight hypochloremia. The emergency non-contrast head CT-scan did not find any infarct, bleeding, space occupying lesion or ventricular enlargement. The patient was directly treated with treatment regimen for meningitis, including intravenous antibiotic injection and corticosteroid. Cerebrospinal fluid (CSF) result was colorless, clear, mononuclear cell predominated (91%) pleocytosis (300 cells/ml), >50% glucose: blood glucose ratio with normal protein. Both the direct Gram smear and acid fast bacillus smear were negative. The thorax X-ray was suggestive of tuberculosis. Mantoux test was not done since the patient had past history of tuberculosis treatment. We assumed that the nonspecific result of the CSF was probably caused by the start of corticosteroid treatment prior to CSF analysis. 
Conclusion: The classic symptoms of meningitis do not always present in every pediatric tuberculous meningitis, even in adolescent. Tuberculous meningitis that is left undiagnosed or lately diagnosed can cause mortality and long-term neurological sequelae. It is important to always rule out tuberculous meningitis in all children presented with headaches and positive meningeal signs with or without fever.
Keywords: symptoms, pediatric, tuberculous meningitis, classic symptoms of meningtitis, children
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