Figure 1
Axial MRI head with contrast
Multiple right cerebellar tuberculomas.
Clinical History
A 25-year-old male presented with fever, headache and confusion. MRI head revealed multiple ring enhancing lesions mainly affecting the cerebellum. The patient developed diplopia shortly after – 6th nerve palsy. Repeat MRI head showed a right caudate infarct and several new ring enhancing lesions.
Imaging Findings
Pulmonary washings in this patient grew Mycobacteria Tuberculosis (TB).
Initial MRI head with contrast - multiple tuberculomas mainly affecting the cerebellum (figures 1 and 2).
Repeat MRI head - high signal on fluid attenuation inversion recovery (FLAIR) images in the right head of caudate nucleus, anterior limb of internal capsule extending into anterior aspect of the right basal ganglia. (Figures 3). The abnormality is of high signal on the true diffusion images (figure 4) and reduced signal on the apparent diffusion coefficient (ADC) images (figure 5). This is a complication of TB vasculitis.
Computed tomography (CT) thorax - widespread miliary nodularity in both lung apices with some cavitation infiltrates (Figure 6 and 7).
Initial MRI head with contrast - multiple tuberculomas mainly affecting the cerebellum (figures 1 and 2).
Repeat MRI head - high signal on fluid attenuation inversion recovery (FLAIR) images in the right head of caudate nucleus, anterior limb of internal capsule extending into anterior aspect of the right basal ganglia. (Figures 3). The abnormality is of high signal on the true diffusion images (figure 4) and reduced signal on the apparent diffusion coefficient (ADC) images (figure 5). This is a complication of TB vasculitis.
Computed tomography (CT) thorax - widespread miliary nodularity in both lung apices with some cavitation infiltrates (Figure 6 and 7).
Discussion
The World Health Organisation ranks TB as the world’s most deadly infectious disease with an estimated 1.4 million deaths in 2015 [1]. 10% of TB patients develop central nervous system (CNS) involvement. This risk is even higher in patients who have AIDS related TB [2-4]. Radiological findings may mimic other infective, non-infective and malignant pathologies. It can take on various forms ranging from tuberculomas and meningitis to spinal and calvarial involvement [5-7].
TB meningitis is a common form of CNS involvement. Leptomeningeal enhancement and enhancing exudates in the Fossa interpeduncluaris are considered sensitive and specific signs of TB meningitis respectively [6, 8, 9]. Findings are better appreciated on post contrast MR imaging compared to CT [5].
Parmar et al. demonstrated FLAIR images to be more specific when compared to contrast-enhanced T1 weighted images in detecting meningeal enhancement [10].
The most common intracranial radiological lesion in CNS TB is a tuberculoma which can present with or without co-existent meningeal involvement [11]. It is usually seen as a lesion with ring like enhancement with little surrounding oedema.
A clinician must be aware of the potential complications of CNS TB which include vasculitis, infarction, hydrocephalus and cranial neuropathies [6, 7]. As in this case, paradoxical enlargement of a pre-existing tuberculoma or development of a new tuberculoma in patients on adequate treatment may be seen. With continued treatment these eventually resolve [12, 13].
TB meningitis is a common form of CNS involvement. Leptomeningeal enhancement and enhancing exudates in the Fossa interpeduncluaris are considered sensitive and specific signs of TB meningitis respectively [6, 8, 9]. Findings are better appreciated on post contrast MR imaging compared to CT [5].
Parmar et al. demonstrated FLAIR images to be more specific when compared to contrast-enhanced T1 weighted images in detecting meningeal enhancement [10].
The most common intracranial radiological lesion in CNS TB is a tuberculoma which can present with or without co-existent meningeal involvement [11]. It is usually seen as a lesion with ring like enhancement with little surrounding oedema.
A clinician must be aware of the potential complications of CNS TB which include vasculitis, infarction, hydrocephalus and cranial neuropathies [6, 7]. As in this case, paradoxical enlargement of a pre-existing tuberculoma or development of a new tuberculoma in patients on adequate treatment may be seen. With continued treatment these eventually resolve [12, 13].
Differential Diagnosis List
• CNS Tuberculosis• Pulmonary Tuberculosis
Neurocysticercosis
Metastasis
Lymphoma
Cerebral abscess
Final Diagnosis
• CNS Tuberculosis• Pulmonary Tuberculosis
References
[1] World Health Organisation (2016) Global Tuberculosis report. Available at: http://apps.who.int/iris/bitstream/10665/250441/1/9789241565394-eng.pdf?ua=1 (Accessed 8/11/2016)
[2] A. Bernaerts, F. M. Vanhoenacker, P. M. Parizel et al (2003) Tuberculosis of the central nervous system: overview of neuroradiological findings. European Radiology vol. 13, no. 8, pp. 1876–1890 (PMID: 12942288)
[3] J. Berenguer, S. Moreno, F. Laguna et al (1992) Tuberculous meningitis in patients infected with the human immunodeficiency virus. The New England Journal of Medicine vol. 326, no. 10, pp. 668–672 (PMID: 1346547)
[4] J. E. Vidal, A. C. P. de Oliveira, F. B. Filho et al (2005) Tuberculous brain abscess in AIDS patients: report of three cases and literature review. International Journal of Infectious Diseases vol. 9, no. 4, pp. 201–207 (PMID: 15964538)
[5] J. Burrill, C. J. Williams, G. Bain, G. Conder, A. L. Hine, and R. R. Misra (2007) Tuberculosis: a radiologic review. Radiographics vol. 27, no. 5, pp. 1255–1273 (PMID: 17848689)
[6] G. Bathla, G. Khandelwal, V. G. Maller, and A. Gupta (2011) Manifestations of cerebral tuberculosis. Singapore Medical Journal vol. 52, no. 2, pp. 124–131 (PMID: 21373739)
[7] V. V. Ahluwalia, G. Dayananda Sagar, T. P. Singh, N. Arora, S. Narayan, and M. M. Singh (2013) MRI spectrum of CNS tuberculosis. Journal, Indian Academy of Clinical Medicine vol. 14, no. 2,pp. 83–90
[8] S. Andronikou, B. Smith, M. Hatherhill, H. Douis, and J. Wilmshurst (2004) Definitive neuroradiological diagnostic features of tuberculous meningitis in children. Paediatric Radiology vol. 34, no. 11, pp. 876–885 (PMID: 15378213)
[9] G. Uysal, G. Kose, A. Guven, and B. Diren (2001) Magnetic resonance imaging in diagnosis of childhood central nervous system tuberculosis. Infection vol. 29, no. 3, pp. 148–153 (PMID: 11440385)
[10] H. Parmar, Y Y. Sitoh, P. Anand, V. Chua, and F. Hui (2006) Contrast enhanced flair imaging in the evaluation of infectious leptomeningeal diseases. European Journal of Radiology vol. 58, no. 1, pp. 89–95 (PMID: 16386866)
[11] Gupta RK, Lufkin RB (2001) MR imaging and spectroscopy of central nervous system infection. Springer US ISBN:0306465515
[12] B. D. Ku and S. Yoo (2009) Extensive meningeal and prenchymal calcified tuberculoma as long-term residual sequelae of tuberculous meningitis. Neurology India vol. 57, no. 4, pp. 521–522 (PMID: 19770574)
[13] B. Afghani and J. M. Lieberman (1994) Paradoxical enlargement or development of intracranial tuberculomas during therapy: case report and review. Clinical Infectious Diseases vol. 19, no. 6, pp. 1092–1099 (PMID: 7888539)
Case information
| URL: | https://www.eurorad.org/case/14249 |
| DOI: | 10.1594/EURORAD/CASE.14249 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 2
Coronal MRI head with contrast
Ring enhancing tuberculomas in the right cerebellum.
Figure 3
Coronal FLAIR MRI head
High signal localising to the head of the right caudate nucleus.
Figure 4
Axial ADC mapping MRI head
On ADC mapping the abnormality in the right caudate nucleus shows a low signal.
Figure 5
Coronal CT thorax
Cavitation infiltrates in the lung apices.
Figure 6
Axial CT thorax
Axial CT with apical nodularity and cavitation of the lungs.
Figure 7
Axial true diffusion MRI head
Right caudate nucleus high signal.
Axial MRI head with contrast
Multiple right cerebellar tuberculomas.
Department of radiology, Birmingham Heartlands hospital, Birmingham, United Kingdom.
Department of radiology, Birmingham Heartlands hospital, Birmingham, United Kingdom.
Coronal MRI head with contrast
Ring enhancing tuberculomas in the right cerebellum.
Department of radiology, Birmingham Heartlands hospital, Birmingham, United Kingdom.
Department of radiology, Birmingham Heartlands hospital, Birmingham, United Kingdom.
Coronal FLAIR MRI head
High signal localising to the head of the right caudate nucleus.
Department of radiology, Birmingham Heartlands hospital, Birmingham, United Kingdom.
Department of radiology, Birmingham Heartlands hospital, Birmingham, United Kingdom.
Axial ADC mapping MRI head
On ADC mapping the abnormality in the right caudate nucleus shows a low signal.
Department of radiology, Birmingham Heartlands hospital, Birmingham, United Kingdom.
Department of radiology, Birmingham Heartlands hospital, Birmingham, United Kingdom.
Coronal CT thorax
Cavitation infiltrates in the lung apices.
Department of radiology, Birmingham Heartlands hospital, Birmingham, United Kingdom.
Department of radiology, Birmingham Heartlands hospital, Birmingham, United Kingdom.
Axial CT thorax
Axial CT with apical nodularity and cavitation of the lungs.
Department of radiology, Birmingham Heartlands hospital, Birmingham, United Kingdom.
Department of radiology, Birmingham Heartlands hospital, Birmingham, United Kingdom.
Axial true diffusion MRI head
Right caudate nucleus high signal.
Department of radiology, Birmingham Heartlands hospital, Birmingham, United Kingdom.
Department of radiology, Birmingham Heartlands hospital, Birmingham, United Kingdom.