PMC6243367_01
Axial CT images of a patient presenting with abdominal distension and pain showing ascites with minimal peritoneal thickening and enhancement. A diagnosis of tubercular peritonitis was made, following which an ascitic tap was performed. Culture of the ascitic fluid showed growth of Mycobacterium tuberculosis. Thus, the diagnosis of tubercular peritonitis was confirmed.
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fig1
A 26-year-old male patient of Indian origin who had previously defaulted on his treatment for tuberculous peritonitis (Figure 1), without other known comorbidities, presented with ptosis and down and outward deviation of the left eye.
Post-contrast axial (left) and coronal T1 weighted images (rightb) showing multiple nodular enhancing lesions in bilateral temporal and parietal regions, preferentially involving the grey-white matter junction, the midbrain and pons of the brain stem, with tuberculous meningitis evidenced by leptomeningeal enhancement.
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(a, b) T2 fluid-attenuated inversion-recovery and T1 weighted axial images show lesions that are T2 hypointense to the cortex, mildly T1 hyperintense to the cortex and isointense to the white matter at the grey-white matter of bilateral insular cortices with perilesional oedema. Lesions are also noted in the sylvian fissure and the prepontine cistern involving the left cerebral peduncle. (c, d) Axial T1 post-contrast images showing ring-enhancing lesions, with involvement of the sylvian fissure in a racemose pattern. (e) Sagittal T1 post-contrast image showing ring-enhancing lesions in the pituitary. (f) Coronal T1 post-contrast image showing involvment of the cavernous sinus on both sides and the floor of the third ventricle.
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Meningeal enhancement was present in the parasellar regions (Figure 3).
Axial T2 fluid-attenuated inversion-recovery and coronal T2 weighted images of the patient following an increase in the size of the tuberculomas (same time as Figure 3) shows a chronic lacunar infarct in the left gangliocapsular region.
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At this time, a chronic lacunar infarct in the left gangliocapsular region was noted (Figure 4).
(a-c) Axial T2 fluid-attenuated inversion-recovery images at 6-month intervals showing mild interval change. The lesion marked with the long arrow is seen to show an interval increase in size despite treatment, while the lesion at the left cerebral peduncle is seen to maintain its size. (d-f) Images showing a racemose pattern (small arrow) of ring-enhancing lesions, which remain almost the same on serial imaging. Serial imaging has been performed thrice at 6-month intervals.
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Two further contrast-enhanced MRI studies of the brain were performed over the next year, 6 months apart (Figure 5).
(a) MR spectroscopy image at the centre of a large tuberculoma showing elevated lactate peak at the third serial imaging. This confirmed central necrosis of the tuberculoma. (b) Image showing the placement of the region of interest.
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MRS showed evidence of reduced choline and N-acetyl-aspartate, with a lipid/lactate peak (Figure 6).