Presentation
Transient left leg paresthesia, left arm shaking and weakness. Normal neurological examination. Swollen finger. Raised inflammatory markers.
Patient Data
Lobulated hyperenhancement in the right frontoparietal region with leptomeningeal enhancement, vasogenic edema and sulcal effacement.
tree-in-bud opacity in the upper zones
peripheral pulmonary nodules - probable intraparenchymal lymph nodes
right hilar and bilateral mediastinal lymphadenopathy
central low attenuation in a right paratracheal node
right posterolateral subcutaneous opacities
Right middle finger:
soft-tissue swelling
deformity of the middle phalanx and PIP joint: possible old pathological fracture
circumscribed lytic areas in the expanded proximal middle phalanx
Large cluster of small, homogeneously enhancing nodules at the high/mid right parietal convexity with suggestion of mild thickening of the overlying dura. The enhancing nodules and associated vasogenic edema are similar to before, suggesting there has not been a significant (short-term) steroid response. Sinus disease with the high density secretions seen on CT possibly representing fungal elements or inspissated secretions.
Case Discussion
Granulomatous disease was suggested on the basis of the intracranial and bone appearances and TB was the primary suspect. Lesions on the lower limbs were compatible with erythema nodosum.
Histopathology:
Stereotactic craniotomy and biopsy of right parietal lesion: Necrotizing granulomatous inflammation within cortex, occasional auramine fluorescent rod-shaped bacteria present suspicious for mycobacteria.
Skin excision subcutaneous lesion of back: Necrotizing granulomatous inflammation.
Right middle finger biopsy - inflamed granulation tissue and multiple well-formed granulomas with areas of necrosis, few microorganisms suspicious for mycobacteria noted.
EBUS of mediastinal lymph node: granulomata.
Final diagnosis: Multi-drug resistant TB which resolved on treatment.
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