Tubercular meningitis with tuberculomas

Case contributed by Dr Abdulrahman Abdo Ali Abbas

Presentation

History of fever, convulsion, and altered consciousness level.

Patient Data

Age: 1 year
Gender: Female

Moderate dilatation of the lateral ventricles, third ventricle, and fourth ventricle with transependymal CSF transudation.

Innumerable small size nodular and ring-enhancing lesions are seen scattered all over the brain involving the cerebral hemispheres, brainstem, and cerebellum, the large lesions show low-intensity center on T2/FLAIR, no surrounding edema or significant mass effect.

Intense diffuse leptomeningeal enhancement in the suprasellar cistern, prepontine cistern, Sylvian fissures as well as an anterior interhemispheric fissure. 

Multiple bilateral areas of diffusion restriction are seen in the periventricular regions and cerebral hemisphere denoting acute infarctions.

Multiple peripheral enhancing neck lymphadenopathy is also present. 

Case Discussion

The MRI shows the classical findings of leptomeningeal and basal cisternal enhancement, communicating hydrocephalus and tuberculomas. The DWI and ADC show the vascular complications in the form of multiple acute infarctions of the basal ganglia and cerebral cortex. Typical caseating neck lymphadenopathy is noted in the axial post-contract T1.

The diagnosis of the case was confirmed by PCR from the patient's CSF.

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