Presentation
Weight loss. Cough. Lower paraparesis.
Patient Data
MRI of brain shows innumerable nodules in cerebral hemispheres, brainstem, cerebellum which are invisible on T1, hypointense on T2, and have surrounding edema on FLAIR. The nodules shows vivid ring enhancement after contrast administration.
Similar solitary ring-enhanced lesion is noted in spinal cord on C3 level.
Diffuse miliary pulmonary nodules. Enlarged mediastinal lymph nodes with central necrosis.
CT shows multiple retroperitoneal, mesenteric, iliac lymph nodes with heterogeneous enhancement (best seen in ileocecal lymph nodes).
Case Discussion
Blood-based PCR test for Mycobacterium tuberculosis was positive. Radiologic studies show a disseminated process within the brain, spinal cord, lungs, mediastinal and abdominal lymph nodes. This is hematogenous dissemination of miliary tuberculosis.
Practical points:
- if tuberculous involvement of lymph nodes is suspected, you should arrange a CT study with contrast administration, because necrotic lymphadenopathy is classical for TB
- innumerable cerebral lesions can be metastases, neurocysticercosis or tuberculomas; first of all, you should exclude primary malignancy elsewhere
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