Case contributed by Jason Szczepanski


2 week history of expressive dysphasia, headaches and ataxia. Febrile. Ex smoker. Previous episode of cough, shortness of breath and weight loss months earlier which resolved without significant treatment after hospitalization.

Patient Data

Age: 60 years
Gender: Male

CTB/CTA/CTV and perfusion studies initially completed.

No intracranial hemorrhage.

Right superior cerebellar hemisphere and peduncle hypoattenuation with ill defined enhancement and nodular focus at white/grey matter junction.

Incidental finding of tree in bud nodules in upper lobe pulmonary tree on CT angiogram (not shown).


In the rostral aspect of the right cerebellar hemisphere there is a cluster of nodular lesions with bright ring enhancement and surrounding vasogenic edema.

There is at least one leptomeningeal lesion in the supratentorial brain, just below the left calcarine sulcus and possibly a nodule more laterally (Coronal T1 +C).

Most likely differential considered to be infection, such as clustered small tuberculomas, or other granulomatous infection. Primary neoplasm is considered less likely.

Case Discussion

The patient subsequently underwent a workup for Tuberculosis.

A lumbar puncture was performed and geneeXpert testing was positive for TB from the CSF sample.

An MRI spine was attempted, but due to pain a limited study was completed. There was no obvious leptomeningeal enhancement on the selected sequences. A CT chest found bilateral extensive tree in bud nodularity.

The patient was commenced on high dose HRZE for a consideration of TB meningitis. He recovered well with an improvement in neurology before discharging home for continued treatment.

This is an interesting case in that the patient's admission months prior (to another center) for cough, shortness of breath and weight loss (13 kg) was the likely commencement of TB activation. This patient was not from a high risk population and not born in an endemic region.

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