PMC9945291_01
(a-f) The first neuroimaging (FLAIR a and b) does not reveal any significant signal changes. Note is made of contrast enhancement anterior to the midbrain on T1 post-contrast (c) (thick arrow). Second neuroimaging (FLAIR d and e) shows extensive hyperintensities in bilateral basal ganglia region. There is also increase in the contrast enhancement in the midbrain on T1 post-contrast (f) (thin arrow). FLAIR: Fluid-attenuated inversion recovery.
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F1
M. tuberculosis, free living microorganism, Gram stain, and microbial cultures were negative. Magnetic resonance (MR) imaging of brain revealed minimal leptomeningeal enhancement in bilateral parafalcine region, and minimal exudates anterior to the midbrain [Figure 1a-c], while spinal cord imaging was normal. Repeated MR neuroimaging showed a marked increase in the radiological features ([Figure 1a-c] represents first neuroimaging, while [Figure 1d-f] represents the second neuroimaging). T2-weighted and fluid-attenuated inversion recovery (FLAIR) hyperintensities in bilateral basal ganglia [Figure 1d and e], along with meningeal enhancement in bilateral parafalcine, frontoparietal lobes, bilateral sylvian fissures, basal cisterns, bilateral cerebellar folia, interpeduncular cistern, and along multiple cranial nerves [Figure 2]. There was thin linear post-contrast leptomeningeal enhancement involving entire spinal cord and nodular enhancement in D12-L1 vertebral level [Figure 3].
T1 post-contrast images. Green and blue arrows show 3rd and 6th cranial nerve enhancement, respectively; red arrow shows enhancement of 7th and 8th cranial nerves in the left internal auditory meatus. Pink arrow shows contrast enhancement of 5th cranial nerve, while the yellow arrow shows nodular contrast enhancement in D12-L1 region.
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F2
T2-weighted and fluid-attenuated inversion recovery (FLAIR) hyperintensities in bilateral basal ganglia [Figure 1d and e], along with meningeal enhancement in bilateral parafalcine, frontoparietal lobes, bilateral sylvian fissures, basal cisterns, bilateral cerebellar folia, interpeduncular cistern, and along multiple cranial nerves [Figure 2]. There was thin linear post-contrast leptomeningeal enhancement involving entire spinal cord and nodular enhancement in D12-L1 vertebral level [Figure 3].
T1 Post-contrast image showing contrast enhancement anterior to the midbrain (red arrow).
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F3
T2-weighted and fluid-attenuated inversion recovery (FLAIR) hyperintensities in bilateral basal ganglia [Figure 1d and e], along with meningeal enhancement in bilateral parafalcine, frontoparietal lobes, bilateral sylvian fissures, basal cisterns, bilateral cerebellar folia, interpeduncular cistern, and along multiple cranial nerves [Figure 2]. There was thin linear post-contrast leptomeningeal enhancement involving entire spinal cord and nodular enhancement in D12-L1 vertebral level [Figure 3]. Most interestingly, she had a rounded M pattern of contrast enhancement in the brainstem [Figures 3].
Fluid-attenuated inversion recovery images 2 weeks post-treatment showing resolution of the previous changes.
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F4
There was reduction in radiological abnormalities as well [Figure 4].