|ECR 2018 / C-2853|
|Tuberculosis where you least expect it – a review of extrapulmonary imaging manifestations|
Findings and procedure details
Case 1: Tuberculous meningitis
A 38 year old man of Middle Eastern origin presented to the Emergency department with:
- severe periorbital and occipital headaches
- 5 episodes of vomiting
- acute confusional state
- neck stiffness
On examination, he was neurologically intact.
His CXR and CT Trunk were unremarkable.
Unenhanced CT scan of the brain showed mild diffuse cerebral oedema.
MRI of the brain demonstrated:
- Pathological high-signal on FLAIR along the cerebral sulci and the ependymal layer of the lateral ventricles with leptomeningeal enhancement following contrast administration. Appearances were consistent with non-specific ventriculitis complicating meningitis, Fig. 1;
- Similar signal was noted in the peri-mesencephalic and ambient cisterns.
Later on, the gentleman received a lumbar puncture, which was negative; and was therefore treated with a broad-spectrum antibiotic, ceftriaxone. CSF analysis in tuberculous meningitis typically portrays lymphocytosis, a high protein content and low glucose levels.
Despite treatment with ceftriaxone, the gentleman`s clinical condition and radiological findings continued to deteriorate into a peri- coning, septic state.
Within a month from admission, the patient developed sudden onset right upper and lower limbs weakness with facial deviation to left.
The MR was repeated and showed:
- A new focal area of restricted diffusion in the left periventricular white matter, Fig. 2.
Findings were consistent with an acute left peri- ventricular infarct.
The gentleman continued to spike fever and his mental state deteriorated.
A repeat MR demonstrated:
- Bilateral thickening of the facial and vestibulocochlear nerves in keeping with TB infiltration, Fig. 3;
- Multiple, scattered ring-enhancing lesions throughout the cerebrum, in keeping with tuberculomas, Fig. 4.
Tuberculomas are hypointense on T1, bright on T2, with T2 shine through on the ADC map and they demonstrate contrast- enhancement.
Follow – up MR, one month down the line, showed:
- Extensive basal meningitis which enhanced avidly following contrast administration and demonstrated leptomeningeal granuloma formation;
- Pathological enhancing soft tissue within the prepontine cistern completely encasing the basilar artery, Fig. 5;
- DWI showed areas of restricted diffusion in the periventricular regions bilaterally due to acute infarction in these regions;
- A similar lesion of restricted diffusion was seen in the pons, Fig. 5.
Overall appearances were again consistent with extensive tuberculous meningitis complicated by acute infarction.
After two months, the fever started to settle and the patinet`s condition started to improve.
A repeat MR Brain showed interval improvement in the degree of signal intensity filling the cerebral sulci. The rest of the findings remained stable in appearance.
The MR spine revealed:
- Extensive plaque-like pathological enhancement covering the surface of the spinal cord predominantly along the dorsal aspect of the thoracic spine, Fig. 6;
- The cord signal was intact;
- The spinal canal was within normal limits throughout.
Case 2: Tuberculous ilietis and peritonitis
A 23 year old man of sub-Saharan origin presented to Casualty Department with severe abdominal pain, profuse diarrhea and anorexia. On examination, the patient had a tense, distended and rigid abdomen with rebound guarding as well as shifting dullness, in keeping with a working diagnosis of a peritonitic abdomen with ascites.
The first CT Abdomen and Pelvis, demonstrated:
- Small bowel wall thickening with mural enhancement and evidence of free fluid. No signs of bowel obstruction were evident, Fig. 7, Fig. 8;
- A left- sided pleural effusions, Fig. 9;
- Pericardial effusion measuring up to 1.5cm in thickness, Fig. 9.
A diagnosis of small bowel TB infiltration was suspected and confirmed by standard antigen testing.
A repeat contrast- enhanced CT Abdomen and Pelvis, showed:
- Diffuse thickening and enhancement of the peritoneum, Fig. 10, Fig. 11, Fig. 12;
- A small amount of free fluid with density of 22HU in the abdomen and pelvis, Fig. 11;
- Right hilar lymphadenopathy, Fig. 13.
Findings were suggestive of tuberculous peritonitis with TB infection of the right lung and right hilar lymphadenopathy.
A diagnosis of disseminated TB was made with standard antigen testing and anti-tuberculous treatment was started. The patient's condition improved and he was discharged to a community care outreach team.
He was re-admitted after a month with worsening distension, left sided abdominal fullness and generalized tenderness. A contrast-enhanced CT scan of the chest, abdomen and pelvis was performed which showed:
- A cavitating lesion in the posterior basal segment of the right lower lobe, Fig. 14. This had increased in size on comparison to the last scan;
- Right basal pleural thickening, Fig. 15;
- Small bowel mural thickening and hyperenhancement;
Diffuse peritoneal enhancement.
Chest findings were in keeping with abscess formation in the posterior segment of the right lower lobe associated with pleural thickening. The diagnosis of TB ileitis was consolidated.
Case 3: Tuberculous lymphadenitis
A 39 year old Sudanese man, with no significant medical history, presented with vague abdominal pain. Ultrasound demonstrated multiple enlarged intraabdominal lymph nodes, measuring up to 4cm, Fig. 16.
The gentleman was referred to our hospital for further evaluation and clinical correlation.
A CT Trunk was performed which showed:
- Pulmonary, left apical tree in bud changes;
- Mediastinal and axillary lymphadenopathy measuring up to 2cm in short- axis diameter;
- Mild splenic enlargement;
- Mesenteric and retroperitoneal conglomerate lymphadenopathy with central necrosis, Fig. 16;
- Mild hepatic enlargement with enlarged lymph nodes at the level of the porta hepatis,Fig. 17;
- Small amount of free fluid seen in the lesser pelvis, Fig. 18.
A differential diagnosis of lymphoma or tuberculous lymphadenitis was established. The blood works revealed that gentleman was HIV and TB positive.
A CT-guided biopsy of the retroperitoneal lymph nodes was performed through a left, posterior abdominal wall approach. The histology and cytology confirmed active TB.
Tuberculous lymphadenitis tends to occur secondary to haematogenous spread from re-activation of TB.
In 40%1of patients presenting with extra-pulmonary manifestations of TB in the United states, the presenting symptom is lymphadenitis.
The gentleman was treated for pulmonary and abdominal TB.
Case 4: Tuberculous osteomyelitis
A 34 year old gentleman, migrant from Sub-Saharan Africa, Hepatitis B positive presented to the Emergency Department with left- sided chest pain and weight loss.
Serial troponin levels and ECG`s were all negative.
An admission chest x -ray showed loss of translucency in the left hemithorax and destruction of the left third posterior rib, Fig. 19.
CT scan of the chest demonstrated:
- Destruction of the posterior segment of the left third rib with complete cortical discontinuity, Fig. 20;
- A peripherally- enhancing, intramuscular fluid collection in the region of the left erector spinae muscle abutting the left trapezius muscle, causing mass effect, Fig. 21;
- A reactive left-sided pleural effusion associated with nodular, enhancing pleural thickening, Fig. 22;
- There was no cervical or axillary lymphadenopathy and the remaining lung parenchyma was otherwise unremarkable;
- No focal scarring from previous pulmonary infections was evident.
Ultrasound- guided aspiration of the intramuscular fluid collection confirmed the diagnosis of TB.
The CT findings were therefore consistent with osteomyelitis of the left third rib together with adjacent tuberculous myositis of the left erector spinae muscle. An adjacent pleural effusion was considered reactive.
Case 5: Renal tuberculosis
A 61 year old female, known case of schizophrenia on multi-drug therapy was being investigated for colorectal carcinoma and her CT Trunk showed:
- Cortical calcification of the upper pole of the right kidney, Fig. 23;
- Bilateral para-pelvic cysts and caliectasis, Fig. 24;
- Calcified right sided para-aortic lymph node, Fig. 24;
- The lower genito-urinary tract was not affected by the disease process;
- No evidence of lymphadenopathy.
The clinical, laboratory and radiological findings tied up with old renal tuberculosis.