Presentation
Headache and dizziness for a week.
Patient Data
Non-contrast CT study of the brain shows focal right cerebellar lobe edema exerting a mass effect on the adjacent fourth ventricle and suggesting an underlying space-occupying lesion.
A contrast-enhanced CT study later that day showed innumerable variable-sized, small ring-enhancing lesions scattered at the grey/white matter interface and also involving both cerebellar lobes and the brainstem.
Non-contrast CT chest (lung window) shows innumerable tiny pulmonary nodules with a random distribution representing miliary shadow.
Case Discussion
In the non-contrast study of the brain, the cerebral changes are very subtle, and the radiologist should be meticulous in picking them up.
This patient presents one of the many faces of intracranial tuberculosis infection, which is intracranial tuberculous granulomata (tuberculomas) with characteristic ring enhancement and distribution.
The presence of miliary densities (pulmonary nodules) helped with this diagnosis.
The patient was immunocompetent and laboratory investigations were negative for bacterial infection or toxoplasmosis. The tuberculosis was endemic in the geographic area, so it was the primary diagnostic possibility for this patient.