Disseminated tuberculosis

Case contributed by Dr Mahmoud Yacout Alabd

Presentation

Acute onset confusional state with past history of fever, cough and abdominal pain.

Patient Data

Age: 24 years
Gender: Female
X-ray

Scattered bilateral reticular and nodular shadows more evident at the right middle and lower zone.

CT

Pre and post contrast CT of the brain showing right occipital and bilateral parietal cortical and subcortical hypodensity with subtle nodular heterogeneous enhancement at the right occipital region as well a linear ring like enhancement see at the para-midline parietal regions bilaterally. 

MRI

TB meningitis with ring enhancing parenchymal lesions (tuberculomas).

CT

Post primary TB of the lungs. TB granulomas at the liver, spleen and kidneys. TB of the spine involving T5, S1 and S2 vertebral bodies with prevertebral and bilateral psoas abscesses. 

MRI

Pott disease of the lumbosacral spine with bilateral iliopsoas abscesses.

Case Discussion

Miliary tuberculosis is a widespread form of the disease as a result of haematogenous spread of Mycobacterium tuberculosis.  It is classically referred to miliary pulmonary tuberculosis which usually appears as miliary pulmonary nodules and pleural effusion on chest radiographs and on CT scans. There can be associated or isolated Extrapulmonary Tuberculosis as a result of this haematogenous spread of the disease, classically appearing a widespread TB granulomas of the affected organ/organs. However certain forms of the disease exists manifesting with specific findings such as TB affection of the CNS (TB meningitis and TB meningoencephalitis) and tuberculous spondylitis (Pott Disease).

It is more common to occur in individuals of lower socioeconomic status. In many cases, such as the one in hand, the presentations of pulmonary TB can be subtle and nonspecific and the patient can present later by extrapulmonary affection which can happen in a wide range of organs. However pulmonary TB is usually present in the form of post-primary affection, which can present in variable forms depending on the severity ranging from scattered reticulonodular opacities, cavitary lesion or widespread miliary TB nodules and pleural affection. TB granulomas can affect many organs including the brain, where it present as ring enhancing parenchymal lesions that has to be differentiated from other ring enhancing lesions, however the presence of meningeal affection narrows the differential diagnosis. TB granulomas can also affect, as in our case, variable abdominal organs such as the liver, spleen and kidneys, and can result in variable degrees of organ dysfunction depending on the severity of affection. Osseous affection is another destination of haematogenous spread of tuberculosis, on top of which is spinal affection or TB spondylodiscitis resulting in abscess formation and the classical Pott disease. Cross-sectional imaging can clearly show the extent of the affected vertebrae and the related paraspinal or epidural fluid collection.  

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Case information

rID: 39290
Case created: 30th Aug 2015
Last edited: 23rd Aug 2017
Inclusion in quiz mode: Included

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