Abstract
Syringomyelia is a rare but recognized complication of tuberculosis (TB) meningitis, typically associated with spinal arachnoiditis and disruption of cerebrospinal fluid dynamics. Although the exact mechanisms are not fully understood, early onset during the acute phase of illness is uncommon. We report the case of a 30-year-old male who presented with progressive neurological symptoms one week after initial evaluation for headache and fever following travel to a TB-endemic region. He developed gait unsteadiness, tremors, and nystagmus and was subsequently found to have a contrast-enhancing lesion near the cerebral aqueduct with early hydrocephalus. Empirical anti-tuberculous therapy and corticosteroids were commenced, but the patient deteriorated, requiring intensive care admission, intubation, and tracheostomy. Over the course of his admission, he developed quadriplegia and was diagnosed with syringomyelia on MRI, involving cervical cord segments C1-C4, alongside extensive spinal cord swelling. Management included modified anti-tuberculous therapy in the context of drug-induced liver injury, ventricular drainage, and immunomodulatory therapy with infliximab for suspected paradoxical TB response. Neurosurgical input advised conservative management of the syrinx due to its small, loculated nature. The patient remained under multidisciplinary care, including complex ventilation support and neurorehabilitation. Decisions regarding surgical versus non-surgical management are guided by factors such as the syrinx's size, location, underlying cause, and the patient's clinical status. In general, surgical intervention is reserved for those with progressive symptoms or worsening radiological findings.