A male, 26 years old, was admitted to our hospital with a fever and altered mental status. He reported a 12-day history of fevers (38-39 C), headaches, photosensitivity, diplopia, and severe fatigue. His relatives stated that he was self-employed, a mild smoker, a non-drinker, and denied drug use. In the emergency department, he was drowsy, febrile (temperature of 38 C), and had a heart rate of 110 beats per minute. He denied having chest discomfort or heart palpitations. The emergency department's Glasgow coma scale score was 13. There was no evidence of rash, bruising, or petechiae. The examination of the patient's respiratory, cardiovascular, and abdominal systems was unremarkable. The neurological examination revealed mild neck stiffness but no meningeal sign.
Studies in the laboratory indicated the following: 5.8 x 109/L white blood cells, 11.2 g/L hemoglobin, 243 x 109/L platelets, 89.5% neutrophils, 3.1% lymphocytes, 126 mmol/L sodium, 4 mmol/L potassium, and 134 mg/dL glucose. Blood cultures did not detect any growth. A chest x-ray indicated no pathology or localized consolidation (Figure 1), and his brain's initial computed tomography (CT) scan was unremarkable (Figure 2). On the third day, the results of his lumbar puncture suggested tuberculous meningitis: clear appearance, increased white cell counts (40/L) with lymphocytes predominating, red blood cells (16/L), high protein (2.09 g/L), and low glucose (40 mg/dL). The cerebral fluid to serum glucose ratio was less than 50%. Both were negative for cytomegalovirus (CMV), toxoplasmosis IgM, and human immunodeficiency virus (HIV) serology.  
The patient was admitted to the hospital ward with meningitis and hyponatremia as his clinical diagnoses. He was initially administered 2 grams per day of ceftriaxone, 10 milligrams per day of dexamethasone injection, hypertonic saline, and paracetamol. The condition improved slightly on the second day. He was treated for tuberculosis meningitis with 10 milligrams per day of dexamethasone injection and a combination of levofloxacin infusion 750 milligrams per day and antitubercular drugs including isoniazid 300 milligrams, rifampin 600 milligrams, ethambutol 1,100 milligrams, pyrazinamide 1,200 milligrams, and pyridoxine 50 milligrams, based on the results of the lumbar puncture. The patient's condition was slightly improved, he was completely conscious, and he continued to suffer from a terrible headache and third nerve palsy. However, the patient's condition suddenly worsened considerably on day seven, manifesting as unconsciousness and seizures.
Eight days after admission, a repeat contrast CT of the brain showed the development of ventriculomegaly suggestive of obstructive hydrocephalus and basilar enhancement (Figure 3). There was an enlargement of the third, fourth, and lateral ventricles. His serum sodium levels decreased (124 mmol/L) over several days. Based on well-established case definition criteria of tuberculous meningitis research, the patient was diagnosed with probable tuberculous meningitis with a total score of 12, which includes clinical criteria (symptom duration of more than five days (4), cranial nerve palsy (1)), cerebrospinal fluid criteria (clear appearance (1), lymphocytic predominance (1), protein concentration greater than one g/L (1), absolute cerebrospinal fluid glucose concentration less than 2.2 mmol/L (1)), cerebral imaging criteria (hydrocephalus (1), basal meningeal enhancement (2)). The patient was transferred to the intensive care unit (ICU) for the insertion of an emergency ventriculoperitoneal shunt. The possibility of complication after shunt insertion was observed. We did not identify complications such as infection, phlebitis, or an exposed shunt in the patient. The patient's condition worsened gradually, and he died ten days after hospital admission.