Hydrocephalus and tuberculous meningitis
647
course is indolent. The reported frequency of
hydrocephalus complicating TBM varies among
different studies. In an earlier study of 58 patients
with TBM, seven patients (12.1%) had hydrocepha-
lus and only four of them (6.9% of all) required
neurosurgical intervention.3 We had a much higher
proportion of TBM patients with hydrocephalus
upon presentation requiring urgent neurosurgical
intervention, comparable to a published study of
48 patients with severe TBM receiving intensive
care, in which 31% of patients had severe hydro-
cephalus requiring neurosurgical interventions.8
Although acute presentation of TBM is common in
our locality,9 hydrocephalus upon presentation is
associated with a longer duration of presenting
symptoms and may be a feature of delayed
presentation.
Prompt CSFanalysis and early initiation of anti-TB
drugs are important when the CSFabnormalities
are compatible with TBM.
In conclusion, hydrocephalus is a common
presenting feature of TBM in Hong Kong. TBM
patients with initial hydrocephalus tend to have a
delayed presentation. Recognizing this feature may
help making an early diagnosis and minimizing
any additional delay in commencement of anti-
tuberculous chemotherapy. Further studies are
required to confirm whether TBM with initial
hydrocephalus is a predictor of severe disease with
a higher risk of stroke and/or poor outcome, and
whether more aggressive treatment is warranted
in such patients.
Focal neurological features upon presentation
indicate stage 2 or 3 disease. Of all focal neurolog-
ical features, the presence of cerebellar symptoms
or signs may be useful in alerting the clinician about
the existence of hydrocephalus. The association
between hydrocephalus upon presentation and stage
2 or 3 TBM suggests that hydrocephalus is an
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