25M with headache and fever Title hidden

Presentation

25M with disseminated TB presents with headache and fever




Diagnosis

  • Multifocal cerebral/cerebellar abscesses with concomitant meningitis
  • Bilateral 5th (V3 segment), 7th, and 8th cranial nerve enhancement is consistent with cranial neuritis
  • Early signs of impending ventriculitis.




Key Findings

  • Numerous ring-enhancing lesions with central restricted diffusion involving the left lentiform nucleus, left mesial temporal lobe, and cerebellar vermis. The cerebellar lesion indents the fourth ventricle. Additional lesion in the right CPA cistern is abutting the cerebellar peduncle and IAC. 
  • Extensive perilesional T2/FLAIR signal hyperintensity consistent with inflammatory edema. 
  • Enhancement of the bilateral 7th and 8th nerves, right greater than left is consistent with cranial nerve inflammation.
  • Enhancement of the trigeminal nerve, V3 distribution in the foramen ovale is consistent with 5th nerve involvement. Bilateral V2 nerves are unremarkable through both the foramen rotundum and infraorbital foramen.
  • Nodular enhancement involving the right lateral subependymal lining raises concern for impending ventriculitis.
  • Asymmetric enhancement about the right cerebellar folia is suspicious for leptomeningeal enhancement.
  • Diffuse pachymeningeal enhancement
  • Nodular enhancing lesion abut the left cavernous ICA





Discussion

  • These findings are likely a sequela of patient's known disseminated tuberculosis. TB meningitis classically has a basal cistern predominance and can involve multiple cranial nerves as in this case. TB abscesses within the brain are much more rare and must be distinguished from tuberculomas, which often have a central T2 hypointensity due to the caseous necrotic material. An excellent review of the CNS imaging findings of TB infection can be found here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306383/
  • The cerebellar vermian lesion appears to indent the fourth ventricle, effacing the CSF space, but there is no evidence of hydrocephalus at this time.
  • Right lateral ventricle subependymal lesion raises concern for impending ventriculitis.
  • Multiple nodular abscesses abut the left cavernous ICA and left PCA vessels, which raises risk for vessel inflammation/mycotic aneurysm formation.