# An Unusual Presentation of Spinal Tuberculosis Masquerading as Pyogenic Meningitis: A Case Report

## TL;DR

A case of spinal tuberculosis was initially mistaken for bacterial meningitis due to similar symptoms, but was correctly diagnosed and treated with anti-TB therapy.

## Contribution

This case highlights the atypical presentation of spinal TB mimicking bacterial meningitis and emphasizes the importance of early imaging and targeted treatment.

## Key findings

- Spinal TB can present with fever, neck stiffness, and CSF pleocytosis resembling bacterial meningitis.
- MRI and CSF PCR confirmed spinal TB despite initial antibiotic treatment failure.
- Anti-TB therapy and corticosteroids led to significant clinical improvement.

## Abstract

Spinal tuberculosis (TB), though accounting for up to 50% of skeletal TB cases, typically presents insidiously with back pain, kyphotic deformity, or neurological deficits. Atypical presentations, including initial neutrophilic pleocytosis in cerebrospinal fluid (CSF), can mimic bacterial meningitis and complicate diagnosis.

We report the case of a 46‐year‐old previously healthy male who initially presented with high‐grade fever, headache, neck stiffness, and neutrophilic CSF pleocytosis suggestive of bacterial meningitis. Despite empirical antibiotic therapy, the patient developed progressive neurological symptoms, including paraplegia and hypertonia. MRI of the spine revealed T2–T6 vertebral body involvement with compressive myelopathy consistent with spinal TB. CSF PCR for Mycobacterium tuberculosis was positive. Anti‐TB therapy and adjunct corticosteroids were initiated, leading to marked clinical improvement.

Clinicians should maintain a high index of suspicion for spinal TB in patients with persistent fever, neurological symptoms, and CSF pleocytosis—especially in TB‐endemic regions—even when initial laboratory findings suggest bacterial meningitis. Early imaging and targeted therapy can significantly improve outcomes.