Disseminated tuberculosis manifesting as pulmonary, meningeal and spinal tuberculosis in an immunocompetent patient

Abstract

Disseminated tuberculosis is characterised by concurrent tubercular involvement of two or more non-contiguous organs. It is an unusual presentation of tuberculosis, especially in the absence of immunodeficiency. We describe a young, immunocompetent patient who presented with fever, cough, headache, diplopia and paraparesis. On examination, the patient had positive Kernig's sign, right third cranial nerve palsy and bilateral sixth cranial nerve palsy, bilateral lower limb weakness and crepititions on lung auscultation bilaterally. Chest radiogram revealed bilateral pulmonary tuberculosis. CT of brain showed hydrocephalus and MRI of spine showed collapse of lumbar vertebrae with paravertebral cold abscess. Sputum microscopy was positive for acid fast bacilli, cerebrospinal fluid analysis was suggestive of tubercular meningitis and CT-guided biopsy of the vertebral lesions revealed caseating granulomas with acid fast bacilli. The patient received antitubercular therapy with initial treatment with steroids and he improved clinically at the end of a 9-month treatment.

Figure 1

Chest radiograph showing bilateral infiltrates suggesting military tuberculosis.

Figure 2

CT of the brain showing communicating hydrocephalus.

Figure 3

(A–D) MRI of spine showing loss of intervening disc space at L3/L4 level with left laterolisthesis of L3 over L4 vertebra with end plate irregularities. Signal intensity alteration seen in L2, L3 and L4 vertebrae. Kyphosis in lumbar spine is visible with marked scoliosis with convexity towards the left. Clumping of cauda equine nerve roots is seen in axial T2-weighted image.