PMC3644770_01
MRI (T1 W axial, postcontrast) showing sequential evolution of right optic nerve tuberculoma (a) diffuse thickening with homogenous enhancement (b) ring enhancement with proptosis (c) necrotic lesion with thicker enhancing rim (after 8 weeks of treatment) (d) reduction in size and degree of enhancement (18 months)
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F1
Magnetic resonance imaging (MRI) brain and orbit at this time (16 weeks after onset of symptoms) revealed a homogenously enhancing, diffusely thickened optic nerve [Figure 1a] with nodular enhancing lesions in the right parietal and frontal lobes. [Figures 2a1 and a2]. A repeat MRI brain revealed conglomerate ring enhancing lesions in right frontal and parietal lobes with perilesional edema, mass effect, and midline shift. [Figure 2b] There was also a 30 x 21 mm ring enhancing lesion in the right optic nerve [Figure 1b] with associated thickening. Repeat imaging at 2 months follow up revealed subtle increase in the size of the right optic nerve necrotic rim enhancing lesion [Figure 1c]. Repeat MRI at 18 months showed significant resolution of the intracranial lesions. [Figure 2d] The optic nerve lesion persisted, though there was a decrease in the size and degree of enhancement [Figure 1d].
MRI brain (T1W axial, postcontrast) showing corresponding images from intracranial parenchymal lesions (a) nodular enhancing parietal lesion (A1) and frontal lesion (A2, coronal) (b) conglomerate ring enhancing lesions in right parietal and frontal lobes with mass effect (c) paradoxical worsening of these lesions (after 8 weeks of treatment) (d) significant resolution in brain lesions (18 months)
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F2
Magnetic resonance imaging (MRI) brain and orbit at this time (16 weeks after onset of symptoms) revealed a homogenously enhancing, diffusely thickened optic nerve [Figure 1a] with nodular enhancing lesions in the right parietal and frontal lobes. [Figures 2a1 and a2]. A repeat MRI brain revealed conglomerate ring enhancing lesions in right frontal and parietal lobes with perilesional edema, mass effect, and midline shift. [Figure 2b] There was also a 30 x 21 mm ring enhancing lesion in the right optic nerve [Figure 1b] with associated thickening. There was remarkable increase in the size, number, and perilesional edema of the brain lesions as well consistent with paradoxical worsening. [Figure 2c] The dosage of steroids was hiked up and ATT was continued. Repeat MRI at 18 months showed significant resolution of the intracranial lesions. [Figure 2d] The optic nerve lesion persisted, though there was a decrease in the size and degree of enhancement [Figure 1d].