MRI Findings and Clinical Outcomes in Tuberculous Meningitis: Insights into Paradoxical Reactions and Disease Progression

Abstract

Objectives: Cases series demonstrating the relationship between brain MRI findings and clinical characteristics, as well as outcomes of patients with tuberculous meningitis (TBM) treated with rifampicin-based regimens over an eight-year period. Methods: This retrospective study included 87 participants aged ≥16 years who were diagnosed with TBM with MRI scans were performed at baseline and three months post-treatment initiation. Clinical outcomes were assessed using the Glasgow Outcome Scale (GOS). Paradoxical responses were defined and analyzed. Ethical approval was granted by the University Hospital Limerick ethics committee. Results: Baseline MRI abnormalities were present in 94% of patients, with meningeal enhancement and tuberculomas being the most common findings. Paradoxical responses were observed in 82% of cases at two months, with new or worsening MRI findings, primarily miliary tuberculomas and meningeal enhancement. Paradoxical reactions did not correlate with six-month mortality. Conclusions: MRI plays a critical role in diagnosing and monitoring TBM. Paradoxical MRI findings, although common, were not predictive of treatment failure or mortality. Teaching Point: MRI findings such as meningeal enhancement and tuberculomas are prevalent in TBM. Paradoxical reactions highlight disease progression but do not indicate treatment failure.