Tuberculous granulomas

Case contributed by Dr Jini P Abraham

Presentation

Severe bifrontal headache for 4 days. Lower back ache for 4 months, aggravated 2 days back.

Patient Data

Age: 20 years
Gender: Male

BRAIN

mri

Ill-defined altered signal intensity lesions in bilateral frontal lobes, splenium of corpus callosum on the left, right globus pallidus and thalamus, midbrain on the right, left temporal lobe, bilateral occipital lobes, and left cerebellar hemisphere. Post-contrast study shows ring enhancement of the lesions in the splenium of the corpus callosum, midbrain, and left cerebellar hemisphere. The rest of the lesions show nodular homogenous enhancement.

Post-contrast FLAIR shows enhancement along sulcal spaces of the left frontotemporal lobe and right frontal lobe, and left Sylvian fissure.

SPINE

mri

T2 hyperintensity with endplate irregularity involving inferior end plate of T12 and superior endplate of L1 vertebral bodies and intervening intervertebral disc, which was indicative of infective spondylodiscitis.

Case Discussion

Lumbar puncture was performed. Mycobacterium tuberculosis was detected in the CSF. The patient was started on ATT and his condition improved.

Various forms of CNS tuberculosis can be detected on imaging evaluation. The most common forms include leptomeningitis, pachymeningitis, tuberculoma, cerebritis, abscess formation, and encephalitis. Each of these forms has its own appearances or may coexist with differential diagnoses on imaging. One of the differential diagnoses, in this case, would be neurocysticercosis, however, leptomeningeal involvement is uncommon and usually involves the basal cisterns.

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