Tuberculous meningitis associated with the absence of pleocytosis in cerebrospinal fluid in an immunocompetent patient: A case report

We report a case of tuberculous meningitis without pleocytosis of the cerebrospinal fluid (CSF) in a 27-year-old patient admitted for a meningeal syndrome with signs of basilar involvement and an infectious syndrome associated with a hacking cough with whitish sputum and night sweats, evolving for 15 days before her admission, in a context of weight loss of 2 kg, asthenia, and anorexia. Cytobacteriological and chemical analysis of the CSF revealed less than 3 cells/mm³ white blood cells, high protein levels of 2.54 g/l, and low glucose levels of 0.08 g/l. Molecular polymerase chain reaction testing of the CSF isolated Mycobacterium tuberculosis DNA. Cerebral magnetic resource imaging revealed multiple intra-axial lesions above and below the tentorial level. The hematologic analysis showed a white blood cell count of 8800/mm³ with lymphopenia of 1360/mm³, platelets 453,000/mm³, and C-reactive protein 17.4 mg/l. HIV-1 and -2 serology, anti-DNA, and anti-nuclear antibodies were negative; serum protein electrophoresis did not reveal polyclonal hypergammaglobulinemia. The lack of CSF pleocytosis in tuberculous meningitis should not rule out this diagnosis in immunocompetent patients.