Tuberculous meningitis is the most frequent manifestation of central nervous system tuberculosis (TB) and is associated with a high morbidity and lethality. The diagnosis of tuberculous meningitis initially relies on the clinical history and on the typical CSF profile: mononuclear pleocytosis, low glucose and elevated protein levels.1 CSF culture takes weeks to obtain results, and PCR for Mycobacterium tuberculosis detection is not widely available in developing countries where the prevalence of TB is higher. In 15–21% of cases, neutrophilic pleocytosis is present at the first spinal tap. Persistent CSF neutrophilia at a second spinal tap 1 week apart identifies a rare condition termed persistent neutrophilic meningitis (PNM).2 In this condition, smears and cultures for common pathogens are negative and there is no response to antibiotic regimens for acute bacterial meningitis.

Here we report three cases of aetiologically proved tuberculous meningitis presenting as PNM in a referral centre for infectious diseases in Rio de Janeiro, Brazil, from 2000 to 2005.

Case reports

Case No 1

A 17-year-old female HIV positive patient was admitted with a 5 day history of fever, headache and nausea. Neurological examination showed no abnormalities. CT of the brain showed diffuse enlargement of the ventricular system. Her T lymphocyte CD4 count …