CNS tuberculosis

   March 26, 2020  Posted in Central Nervous System, Infection

Clinical:

  • An 18 years old girl
  • Recently diagnosed smear positive PTB
  • Complicated by recurrent pneumothorax
  • Presented after one month of diagnosis and on TB medication with tonic clonic seizures
Chest radiograph PA erect view

Chest radiograph findings:

  • Extensive lesions in both lungs, mainly small cavities
  • Some confluent areas are see
  • Right pneumothorax with visualization of pleural lining (white arrow) and no lung markings peripheral to it
  • No mediastinal shift is seen
  • There is right pleural effusion seen as blunted right costophrenic angle (yellow arrow)
Contrast-enhanced CT brain in axial plane, soft tissue window

CT scan findings:

  • There are multiple small rounded enhancing lesions in the brain parenchyma
  • Most of the lesions are peripherally located at cortical regions.
  • The largest in right frontal lobe is associated with perilesional oedema.
  • There is slight meningeal enhancement seen at right temporal lobe.
  • No hydrocephalus.
MRI brain in axial plane< T1_weighted images post gadolinium

MRI findings:

  • There are multiple small homogeneously nodular enhancing lesions in the cerebellum and cerebrum (yellow arrows)
  • The lesions are seen peripherally located adjacent to the sulci may be arising from the leptomeninges of the cerebellum, bifrontal and in the right sylvian fissure.
  • The subjacent gyri show white matter oedema, especially at the right middle frontal gyrus where the largest leptomeningeal lesion is seen.
  • Leptomeningeal enhancements are seen (red arrows)
  • No abnormal enhancement at leptomeningeal region.

Diagnosis: CNS tuberculosis (meningitis and tuberculomas) with pulmonary TB.

Discussion:

  • Involvement of the CNS is seen in about 5% of patients with pulmonary tuberculosis
  • CNS tuberculosis usually results from hematogenous spread.
  • CNS tuberculosis can manifest in many forms, including tuberculous meningitis, tuberculomas, tuberculous abscesses, tuberculous cerebritis, and miliary tuberculosis.
  • Tuberculous meningitis is the most common manifestation of CNS tuberculosis
  • The most common CNS parenchymal lesion of tuberculosis is tuberculoma, also known as tuberculous granuloma.
  • Tuberculomas can exist in conjunction with tuberculous meningitis
Author: radhianahassan