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Images in Neurology |

The Many Faces of Central Nervous System Tuberculosis

Graciela Cárdenas, MD; José Luis Soto-Hernández, MD
Arch Neurol. 2011;68(8):1078. doi:10.1001/archneurol.2011.169.
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Central nervous system involvement is the most devastating form of tuberculosis. A high mortality and severe neurological sequelae1 are consequences of a delayed diagnosis due to heterogeneous clinical and neuroimaging manifestations. We present some central nervous system tuberculosis cases; all patients had histopathologic or culture evidence of tuberculous bacilli. Gadolinium-enhanced magnetic resonance imaging (MRI) findings ranged from focal leptomeningitis to tuberculomas (Figure). Four patients developed new lesions under antituberculous treatment for tuberculous meningitis.

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Figure. Gadolinium-enhanced magnetic resonance imaging. A, Coronal plane; leptomeningitis on left Sylvian fissure of a 35-year-old man. B, Axial plane; diffuse basal enhancement and encephalitic areas on the brainstem, hippocampi, and gyri rectus of a young woman. C, Axial plane; multiple ependymal and septal granulomas in a 38-year-old man with changes in mental status and unstable gait. D, Coronal plane; left hemispheric cerebellar tuberculoma with fourth-ventricle compression and obstructive hydrocephalus. Patient had a 1-year history of ataxia, tremor, and abnormal gait. E, Coronal plane; giant multiloculated right frontal tuberculoma. Patient had chronic intracranial hypertension and acute visual loss. F, Axial plane; cisternal tuberculomas expanding to the right hippocampus and compressing the brainstem, which appeared as a paradoxical response to antituberculous treatment, in a 32-year-old woman. G, Sagittal plane; multiple tuberculomas, predominating at the optochiasmatic region, appeared as a paradoxical response for miliary tuberculosis in a 17-year-old girl. H, Axial plane; a single tuberculoma developed after 8 months of treatment in an elderly woman with a 2-year history of granulomatous uveitis. I, Sagittal plane; a tuberculous brainstem abscess appeared at 7 months of treatment for miliary tuberculosis in a 24-year-old woman.




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