Presentation
Patient with chronic kidney disease, having already undergone kidney transplantation, presenting episodes of seizures.
Patient Data
Non-enhanced chest CT shows uniform-sized tiny 2-3 mm pulmonary nodules randomly distributed throughout both lungs, characteristic for miliary disease.
Impression
Classic pattern of miliary tuberculosis.
Non-enhanced cranial MRI reveals numerous lesions in the cerebellar and cerebral hemispheres which are hypointense on T1WI and hyperintense with a peripheral hypointense rim on T2WI. The lesions demonstrate restricted diffusion characterized by low apparent diffusion coefficient (ADC) and hyperintensity on the diffusion-weighted image (DWI), with surrounding edema.
Impression
These findings are consistent with caseating tuberculomas with liquefactive necrosis centrally or tuberculous abscess, both of which are indistinguishable on MRI.
Follow-up contrast-enhanced cranial MRI reveals a significant decrease in the abscess/caseating tuberculomas, presenting as numerous bilateral lesions with a ring or nodular enhancement in the cerebral and cerebellar hemispheres and marked amelioration of surrounding edema. The two larger lesions in the right middle temporal gyrus and the ipsilateral paracentral lobe demonstrate restricted diffusion and annular enhancement, representing caseating tuberculomas with central liquefaction/tuberculous abscess. There are still several small foci of marked SWI hypointense signal related to calcification or bleeding.
Impression
Multiple brain lesions related to CNS tuberculosis - tuberculomas/abscesses.
Case Discussion
Tuberculosis is an infectious disease whose incidence has increased because of HIV and immunosuppressive drugs 1-6. Pulmonary Miliary tuberculosis should be a warning for investigation of CNS tuberculosis, especially in immunocompromised patients 1-6. Brain tuberculomas with central liquefaction and tuberculous abscess are indistinguishable on MRI, and they also have a similar appearance with pyogenic cerebral abscesses 2,3,5. Early diagnosis is essential and determines the clinical outcomes; therefore, radiologists must be familiar with the various imaging presentations of tuberculosis 1-5.
This case demonstrates classic pulmonary miliary tuberculosis with CNS tuberculosis, confirmed by clinical, chest CT images, brain MRI and CSF criteria.
Case courtesy
- Isabela Oliveira, MD – PGY-2, radiology resident, Department of Radiology
- Rennah Gonçalves, MD – PGY-3, radiology resident, Department of Radiology
- Antonio Rodrigues de Aguiar Neto, MD - radiologist, Department of Radiology
Hospital da Restauração – Recife, PE – Brazil
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