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Tuberculous meningitis: cerebral tuberculomas and spinal cord involvement

Case contributed by Ammar Haouimi
Diagnosis almost certain

Presentation

Six weeks history of low-grade fever, headaches, and malaise with altered mental status, and paraparesis one week before the MRI exam.

Patient Data

Age: 20 years
Gender: Male

The MRI sequences demonstrate intense and extensive thickening with nodular enhancement of the basal subarachnoid cisterns, along the middle cerebral arteries to the Sylvian fissures. Mild dilatation of the 3rd and lateral ventricles suggesting associated obstructive hydrocephalus.

Diffuse leptomeningeal enhancement is seen as nodular and linear enhancement along the cerebellar surface as well as at the cerebral hemispheres with small tuberculomas at the left Sylvian regions. A small left corona radiata area of high signal on FLAIR and T2WI most likely a focal established infarct (no restricted diffusion).

Extensive linear and nodular thickening with enhancement along the entire spinal cord up to the cauda equina. 

Case Discussion

A lumbar puncture was performed with CSF analysis showing: pleocytosis, elevated protein levels, low glucose level, and increased WBC count.

The MRI features and CSF analysis are suggestive of tuberculous meningitis with cerebral tuberculomas and spinal cord involvement.

 

Additional contributor: A. Ramdani, MD

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