To describe two patients with autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy whose initial presentation and treatment response mimicked those of tuberculous meningitis.

As delayed treatment of tuberculous meningitis can lead to fatal consequences, it is not uncommon for patients to be empirically treated with anti-tuberculosis treatment before diagnostic assay and culture results become available, especially in regions where tuberculosis is endemic. Autoimmune GFAP astrocytopathy, a steroid-responsive disorder, could mimic clinical presentation and initial response to anti-tuberculosis therapy.  

Patient 1: A 56-year-old man presented with 2-week history of fever, headache, dizziness and confusion. He had nystagmus, ataxia and tremors. Cerebrospinal fluid (CSF) examination showed lymphocytic pleocytosis with elevated protein. There was leptomeningeal enhancement of the brainstem and cervical cord on magnetic resonance imaging. Anti-tuberculosis  treatment with tapering steroids were started for tuberculous meningitis. The patient demonstrated clinical, CSF and radiologic improvement initially, but ataxia and confusion later recurred during steroid taper. Investigations showed GFAP-IgG in the CSF. He was reinitiated on high dose steroids with improvement.

Initial clinical features of autoimmune GFAP astrocytopathy may be difficult to distinguish from tuberculous meningitis. Autoimmune GFAP astrocytopathy should be suspected in patients with neurological deterioration and paradoxical reaction of tuberculous meningitis, and confirmed by detection of GFAP-IgG in CSF.