Atypical Cerebral Manifestations of Disseminated Mycobacterium tuberculosis

Abstract

Background: We investigated the patterns of cerebral manifestations in patients with underlying pulmonary or extrapulmonary tuberculosis or disseminated tuberculosis.

Materials and methods: From January 2010 to September 2016, brain magnetic resonance imaging (MRI) scans were obtained to evaluate cerebral manifestations in patients with underlying pulmonary or extrapulmonary tuberculosis. We also included patients with drug-resistant tuberculosis or disseminated tuberculosis. MRI findings of tuberculous meningitis and tuberculoma were classified as typical; other MRI findings were classified as atypical. Demographic data, risk factors, and drug regimens were collected and analyzed.

Results: Twenty-two patients were diagnosed with cerebral tuberculosis. Cerebral tuberculosis was due to hematogenous spread from pulmonary tuberculosis (10 patients), spinal tuberculosis (8 patients), disseminated tuberculosis (3 patients), and unknown causes (1 patient). There were six patients with typical MRI findings (three patients with typical meningitis involving the basal cistern and supratentorium, one patient with tuberculomas, and two patients with both) and seven patients with atypical MRI findings [five patients with evidence of early meningitis, such as high signal intensity on fluid-attenuated inversion recovery (FLAIR) along the cerebellar folia, and two patients with only hydrocephalus].

Conclusion: Besides the typical sites of meningeal involvement, overlooked findings such as FLAIR abnormalities along the cerebellar folia or hydrocephalus should be checked for early detection of cerebral tuberculosis and initiation of the appropriate treatment against disseminated tuberculosis.

Keywords: atypical tuberculosis meningitis; disseminated tuberculosis; post-contrast fluid-attenuated inversion recovery; tuberculoma; tuberculous meningitis.

Figure 1

Brain magnetic resonance images of a 50-year-old woman with headache, nausea, and vomiting. (A–C) Post-contrast T1-weighted images show linear meningeal enhancement along the cerebral sulci and midbrain surface (arrow). (D–F) Fluid-attenuated inversion recovery images show high signal intensities occupying the subarachnoid space, compatible with tuberculosis meningitis.

Figure 2

Disseminated tuberculosis in a 72-year-old woman with pain in both lower extremities with underlying active pulmonary tuberculosis. (A) Spinal magnetic resonance (MR) T2-weighted images show intermediate to slightly high signal intensities and cord edema at the T7–L1 level. (B) Post-contrast T1-weighted images with fat suppression, taken at the same level as the images in panel (A), show rim enhancement at the intramedullary portion of the conus medullaris, suggesting a tuberculous abscess. (C) Initial post-contrast T1-weighted brain MR image shows multiple tuberculomas with rim enhancing pattern. (D) Follow-up MR image shows regression of tuberculomas after a 1-month anti-tuberculosis treatment.

Figure 3

Disseminated tuberculosis case in a 22-year-old man with headache and diplopia. (A) The patient was diagnosed with active pulmonary tuberculosis based on chest computed tomography (CT). (B) Neck ultrasound shows eccentric necrosis in the enlarged lymph nodes of the neck, suggestive of tuberculosis lymphadenitis. (C) Abdominopelvic CT shows mesenteric lymphadenopathy (yellow arrows) and retroperitoneal lymphadenopathy (not shown), suggestive of tuberculosis lymphadenitis. (D–G) Post-contrast T1-weighted magnetic resonance images show rim enhancing tuberculoma [(D), arrow], thick, irregular enhancement of the right trigeminal nerve [(E), arrow], and linear leptomeningeal enhancement along the cerebral sulci, cerebellar folia, and the surface of the brain stem [(F,G), arrows].

Figure 4

Atypical tuberculous meningitis in a 45-year-old man with low back and radiating pain. (A) Spine magnetic resonance (MR) shows subligamentous spreading pattern of spondylitis with T6–7 endplate erosion and paravertebral abscess formation (arrows), suggestive of tuberculous spondylitis. (B) One month later, the patient became mentally confused. Post-contrast T1-weighted MR images show linear high signal intensities along the pial surface of the infratentorium, including the cerebellar folia and surface of the brainstem. (C) Matching fluid-attenuated inversion recovery images also show subtle abnormal high signal changes along the pial surface of the infratentorial structures.