8th Baltic Congress of Radiology

Neuroradiology

poster abstract

Tuberculosis (TB) is a significant cause of ill health and one of the primary causes of death worldwide. TB was the leading cause of death from a single infectious agent, ranking above HIV/AIDS, until the coronavirus (COVID-19) pandemic. In 2020, there were an estimated 9.9 million (8.9-10.9 million) new cases with TB worldwide, of which 5.5 million were men, 3.3 million were women and 1.1 million were children. 1.5 million people died from TB. Only 1-10 % reports CNS-TB of all TB cases, it has the highest mortality and morbidity among all TB infections Most common of CNS involvement is tuberculous meningitis (TBM). Only about 10% have a history of prior TB and only pulmonary TB. Another cerebrovascular complication of TBM is vasculitis, appears typically as multiple or bilateral lesions in the territories of the middle cerebral artery perforating vessels. Most of the infarcts are in the basal ganglia and internal capsule regions because of the involvement of the lenticulostriate arteries. We would like to report a 17- years old girl from Vietnam, currently living in Latvia with central nervous system tuberculosis, as well as miliary pulmonary tuberculosis, uveitis both eyes.

Patient was sent to the children’s hospital for a circa two-week history of persistent subfebrile/ febrile temperature, also in last week there was also vertigo and difficulties walking because of instability. Communication with girl was difficult, because of the language barrier. Last time visited Vietnam 3 years ago. There is no data regarding TB vaccination, although she did have a scar on forearm. HIV test, as well as immunologic screening for possible immunodeficiencies were negative. In first brain CT was found a huge hypodense edema zone in the right temporal lobe, thalamus, pons, cerebellum. Later that day in MR report -edema in brain right side, thalamus, temporal lobe upper part, right parietal lobe, mesencephalon, middle cerebellar peduncle, right cerebellum, right trigeminal nerve. In basal cisterns leptomeningeal enhancement. Diagnosis -meningoencephalitis, possibly tuberculosis. In lumbar punctate -lymphocytic pleocytosis elevated protein levels, decreased glucose levels. CT for the lungs was done, there was multiple small lesions- miliary tuberculosis. 5 days later another CT brain, images showed obstructive hydrocephaly, ventriculoperitoneal shunting was done, MR showed disease progression with dissemination, milliary tuberculomas. 21 days after admission urgent MRI was done, showed acute cerebral infarction in left middle cerebral artery. In follow up MR examinations reported narrowing and irregularity of arcus of Willis vessels consistent with vasculitis.

The diagnosis of CNS TB was confirmed in our patient in meningitic phase, considering 2 weeks history of nonspecific symptoms and finding of small nodules in chest CT, also lumbar puncture results helped. Final diagnosis was acute milliary TB involving brain, lungs, and eyes. Our patient's brain MRI showed leptomeningeal enhancement, brain edema, tuberculomas, also radiologic manifestations of TB complications -progressive hydrocephalus, vasculitis, infarction, and cranial neuropathies. CNS TB results from hematogenous spread form distant infection like pulmonary TB, probably in our patients’ case or direct extension from local infection like TB otomastoiditis. CNS TB appearances contain extra-axial leptomeningitis (very common), TB pachymeningitis (rare). Intra-axial intracranial TB contain abscess, rhombencephalitis, encephalopathy  Typical MRI characters of CNS TB include basal meningeal enhancement and hydrocephalus, while brain tuberculomas appear as nodular lesions, well seen in postcontrast images.

CNS TB remains common and, despite the availability of effective anti TB therapy, continues to cause significant morbidity and mortality. Early diagnostics of CNS TB is challenging because clinical and laboratory manifestations can mimic many infectious and noninfectious diseases. The clinical features vary according to the site of infection and are usually nonspecific. Imaging modalities for example CT and MR imaging plays large role in diagnosis of CNS TB. In conclusion miliary brain tuberculomas are exceptional radiological and clinical structures. Our patient, before being transferred to another hospital, has not yet recovered. She has minimal verbal contact, cognitive deficit, confusion, asymmetric tetraparesis. PEG feeder was inserted. Palliative patient.

Miliary brain tuberculomas, are very rare, often linked with miliary pulmonary TB infection. We report a rare case with 17 years old immunocompetent patient with miliary brain tuberculomas, milliary lung TB and TB in eyes, presented with a history of sub/febrile temperature, vertigo, unsteady gait. MRI revealed brain edema, basal cisterns leptomeningeal enhancement, tuberculomas, complications of TB progressive hydrocephalus, vasculitis, infarction, and cranial neuropathies.

1268