Imaging manifestations of pediatric central nervous system tuberculosis in an endemic region

Abstract

Tuberculosis of the central nervous system is a deadly disease with a high mortality and morbidity rate. While tuberculosis is prevalent worldwide, most active cases are found in underdeveloped and developing countries, including Pakistan, where it is highly endemic. The pediatric population is particularly at high risk of developing CNS tuberculosis. This disease can manifest in various forms, such as tuberculous meningitis, tuberculoma, tubercular abscess, Pott's spine, and tuberculous arachnoiditis. Given that the prognosis of CNS tuberculosis is closely tied to the stage at which treatment begins, it is crucial to make an early and accurate diagnosis using MRI. In this case series, we present four pediatric patients who presented with a wide array of symptoms, ranging from fever and seizures to drowsiness. The current study focuses on the radiological presentation of CNS tuberculosis in the pediatric population, with the hope that it may help address the gap in the lack of available case reports on CNS tuberculosis in Pakistan, an endemic country.

Keywords: Central nervous system; Pediatric population; Tuberculoma; Tuberculosis.

Fig. 1

(A) Axial T2-weighted MRI, (B) Susceptibility-weighted image (SWI), (C) Axial post-contrast T1-weighted image, and (D) Sagittal post-contrast T1-weighted image demonstrate multifocal supratentorial and infratentorial tuberculomas (arrows), showing T2 hypointensity, signal dropout on SWI, and ring enhancement on post-contrast sequences. (E, F) Coronal post-contrast FLAIR images show diffuse meningeal enhancement, most prominent at the basal cisterns (arrowheads).

Fig. 2

(A, B) DWI and corresponding ADC images showing multifocal vasculitic infarcts involving the genu of the corpus callosum and right basal ganglia (arrows). (C, D) Post-contrast T1-weighted sagittal and axial images demonstrating diffuse leptomeningeal enhancement (arrowheads) involving the basal and perimesencephalic cisterns, interpeduncular and prepontine cisterns, and bilateral optic nerves.

Fig. 3

(A, B) DWI and corresponding ADC images showing multifocal vasculitic infarcts in the left genu of the corpus callosum and left basal ganglia (arrows). (C) Post-contrast FLAIR coronal image and (D) post-contrast T1-weighted axial image demonstrating enhancement of the optic nerves and chiasm (arrowheads).

Fig. 4

(A, B) DWI and corresponding ADC images showing an acute infarct in the splenium of the corpus callosum (arrow). Mild hydrocephalus is also noted. (C, D) Post-contrast T1-weighted axial images demonstrating basal meningeal enhancement and perineural enhancement along the bilateral facial and vestibulocochlear nerve complexes (arrowheads). (E, F) Post-contrast T1-weighted sagittal images showing ring-enhancing lesions (broad arrows).