Tuberculous meningitis

Case contributed by Dr Salvatore Belluardo

Presentation

Headache, neck stiffness, photophobia and fever.

Patient Data

Age: 50 years
Gender: Female
CT

A focal area of gyral swelling and spontaneously hyperdense at the left parieto-temporal region with reduced representation of the posterior ascending branch of the left Silvian fissure. 

After contrast there is a marked leptomeningeal enhancement, clearly more represented in the late phase, suggesting focal meningitis. Significantly more evident picture in the advanced phase.

No acute intracranial hemorrhage. No midline shift.

MRI

Day 5

A focal area of gyral swelling and T2 and FLAIR tenuous hyperintense at the left parietotemporal region with reduced representation of the posterior ascending branch of the left Silvian fissure. In the same area, weakly hyperintense signal in DWI and marked nodular leptomeningeal enhancement are appreciated. Focal meningeal involvement is clearly demonstrated.

Pencil-thin line of hyperintensity T2 and FLAIR surrounds ventricles. Some T2 and FLAIR hyperintense punctate foci in the sub-cortical and deep white-matter is also appreciated. 

MRI

Day 8

The appearance of numerous minute cortical areas characterized by hyperintense signal in DWI and low ADC is highlighted on the left in the posterior areas of the insular lobe, in the postero-lateral frontal lobe and parieto-occipital mesial region and some also on the right in the frontal and parietal lobe, in the mesial temporal region and periventricular seat as well as in both cerebellar hemispheres. 

MR angiography shows a slight reduction in the caliber of proximal anterior and middle cerebral arteries as well as the supraclinoid portion of the internal carotid arteries which present fine marginal irregularities.

Persist focal meningeal involvement in the left parieto-temporal region.

CT

Day 14

No evidence of lung involvement.

MRI

Day 24

The foci of restricted diffusion highlighted in the previous MRI have almost completely disappeared; contrast enhanced T1-weighted images shows some millimetric foci of pathological enhancement in the same locations, especially in the parieto-occipital mesial region, and thick meningeal enhancement at the interpeduncular cistern. Focal meningeal involvement in the left parieto-temporal region is somewhat less evident.

Two minute cortical foci of restricted diffusion appeared on the right in the pre-central gyrus and in the parietal lobe.

MR angiography shows significant reduction in the caliber of the supraclinoid portion of the internal carotid arteries and in particular of the proximal anterior and middle cerebral arteries which appear irregular and reworked in relation to arteritis.

CT

Day 27

Acute infarct in the right basal ganglia.

CT

Day 27

Contrast-enhanced abdominal CT shows a cortical hypoattenuating granuloma in the left kidney.

Case Discussion

An immunocompetent patient was found negative at the QuantiFERON-TB test. CSF study revealed a clear appearance, decreased sugar level, pleocytosis and increased protein and immunoglobulin G (IgG). Mycobacterium tuberculosis was isolated from the cerebrospinal fluid.

Imaging features are consistent with tuberculous meningitis and arteritis and with kidney tuberculoma. No evidence of lung involvement. This case also shows that there is an increased incidence of ischemic strokes in cases of basal tuberculous meningitis (due to arteritis).

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Case information

rID: 75428
Published: 5th Apr 2020
Last edited: 5th Apr 2020
Inclusion in quiz mode: Included
Institution: UOC di Radiologia, PO R.Guzzardi di Vittoria, ASP di Ragusa

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