Tuberculous meningitis

Case contributed by Dr David Mitchell

Presentation

Altered conscious state

Patient Data

Age: 60
CT

Day 1

Hydrocephalus. Periventricular white matter low density changes in keeping with transependymal edema. No acute intracranial hemorrhage. No midline shift. No intra-axial lesion seen. Permeative changes of the clivus.

MRI

Day 2

Conclusion: Acute hydrocephalus, post ventricular drain insertion. Combination of osseous, leptomeningeal and subependymal enhancing lesions.

Perimesencephalic leptomeningeal enhancement and enhancement along the cranial nerves in the prepontine and cerebellopontine angle cisterns. At the vertex there is sulcal FLAIR hyperintensity.  Small foci of nodular enhancement related to the left foramen of Luschka, which is completely obliterated. 

Interval placement of right frontal approach ventricular drain. Periventricular T2/ FLAIR hyperintensity most likely represents transependymal CSF leakage. The cerebral aqueduct appears widely patent and there is a normal T2 flow void which implies patency. 

An enhancing abnormality within the clivus and extending into the right occipital condyle and left petrous apex and petroclival junction.

CT

Day 3

Changes of the inferior endplate of T7 and superior end plate of T8 combined with paraspinal fluid / soft tissue changes.

MRI

Day 5

Marked progression of imaging findings compared to recent MRI. In particular, there is now extensive leptomeningeal enhancement, most marked about the brainstem and basal/suprasellar cisterns. New right midbrain FLAIR hyperintense changes with adjacent new right basal ganglia acute infarcts. 

MRI

1 month post presentation

Marked progression of the extensive thick and nodular leptomeningeal enhancement. Multiple acute infarcts involving the basal ganglia and brainstem.

Case Discussion

Presentation of acute hydrocephalus and a combination of osseous, leptomeningeal and subependymal enhancing lesions.

Given the rapidity of change, appearances favor an infective process such as tuberculosis (TB), rather than metastases, lymphoma or sarcoidosis.

This patient's CSF initial gram stain and culture were negative. However, the presumed T7/T8 diskitis/osteomyelitis was biopsied under CT guidance. Although the gram stain form this biopsy was negative and there were no acid-fast bacilli identified; the subsequent PCR test and extended culture were positive for TB.

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Case information

rID: 61290
Published: 27th Jun 2018
Last edited: 28th Jun 2018
Inclusion in quiz mode: Included

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