Tubercular Meningitis (TBM), a severe form of extra-pulmonary tuberculosis, often presents with non-specific and insidious symptoms, making early diagnosis challenging. Classical features such as fever and neck stiffness may be absent or subtle, while psychiatric manifestations like apathy, irritability, and personality changes may predominate.

We report the case of a 23-year-old female who presented with apathy, reduced appetite for two weeks, sleep disturbances, and perseverative speech (“I want to log in”) for one day, in the background of significant work stress. She was initially diagnosed with acute stress reaction and managed with antipsychotics. However, on the second day of admission, she developed confusion, visual hallucinations, and delirium.

Initial CT brain imaging was normal. Further evaluation with contrast-enhanced MRI revealed basal exudates and leptomeningeal enhancement suggestive of tubercular granulomas. Cerebrospinal fluid analysis confirmed Mycobacterium tuberculosis infection. The patient required intensive care and had a prolonged hospital stay complicated by infarcts, antitubercular therapy-induced hepatitis, hemiparesis, and speech disturbances. Gradual improvement was noted with physiotherapy and speech therapy.

This case highlights the diagnostic difficulty of TBM when presenting with predominant psychiatric symptoms and normal initial neuroimaging. It underscores the importance of maintaining a high index of suspicion for organic etiologies, especially in atypical psychiatric presentations, and the need for timely neuroimaging and CSF analysis to reduce morbidity and mortality.

Sandesh Hegde is a Consultant Psychiatrist with an MD and DNB in Psychiatry. He is currently working as a Senior Resident at KS Hegde Charitable Hospital, Mangalore, India. His clinical work includes inpatient and outpatient psychiatry, liaison psychiatry, and de-addiction services. He has experience managing complex psychiatric cases, including presentations with underlying organic etiologies. He is actively involved in teaching undergraduate and postgraduate students, conducting academic sessions, and participating in research and journal discussions. He has hands-on experience in modified electroconvulsive therapy (MECT), psychotherapy, and emerging treatments such as ketamine therapy. His areas of interest include neuropsychiatry, consultation-liaison psychiatry, and early identification of medical conditions presenting with psychiatric symptoms.