Multisystem tuberculosis

Presentation

Fever, headache, and progressive neurological impairment.

Patient Data

Age: 30 years
Gender: Male

PA CXR

X-ray

There is left hilum thickening consistent with lymphadenopathy. Innumerable bilateral upper field predominant micronodules, compatible with a miliary pattern.

Pre and contrast enhanced

CT

There are multiple ring-enhancing supra- and infratentorial lesions associated with peripheral vasogenic edema. The most extensive infratentorial lesion is located in the cerebellar vermis and compresses the fourth ventricle with consequent supratentorial hydrocephalus.

CT TAP

CT

Chest window coronal CT shows numerous bilateral micronodules in random distribution and with upper lobe predominance.

The soft tissue window shows bilateral and perihilar mediastinal lymphadenopathy. Right axillary lymphadenopathy with a necrotic center.

Multiple hypodense nodular lesions affecting the liver and splenic parenchyma compatible with septic embolism. 

MRI brain

MRI

Post-contrast T1W images show multiple supra and infratentorial ring-enhancing intraparenchymal lesions located in the cortico-subcortical junction.

FLAIR images show associated perilesional vasogenic edema.

Post-contrast FLAIR images show leptomeningeal enhancement affecting cranial nerves V, VII, VIII, typical of TBC in the central nervous system.

There is no restriction on diffusion-weighted images which means abscesses are unlikely.

The findings were in keeping with tuberculomas.

Lumbar spine

MRI

There is a localized bone lesion in the vertebral body T10, with peripheral contrast uptake and irregular contrast suggestive of tuberculosis spondylitis.

Case Discussion

The set of radiological findings were highly suspicious of tuberculosis, so samples were taken and antituberculous treatment was started. Two days later the diagnosis was confirmed with positive nucleic acid amplification (NAA) tests for tuberculosis from a sample of bronchial alveolar lavage secretion.

HIV serology was negative.

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