PMC9301103_01
Timeline of the clinical course.
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F1
The patient was reported to have lost 35 kg during the last 2 years (Figure 1). However, his health status continued to gradually worsen, with the highest body temperature reaching 39 C, with confusion, occasional nonsense, and partial third cranial nerve palsy, on day 3 (Figure 1).
(A) Computed tomography (CT) of the chest showing patchy high-density shadows in the upper lobes of both lungs (white arrow), suggesting secondary to tuberculosis. (B) CT scan revealed thickening of the left pleura and encapsulated effusion (white arrow). (C) T2-weighted magnetic resonance imaging (T2WI) FLAIR showing small circular isointense, slightly long hyperintense in the right lateral ventricle subependymal (white arrows). (D) Contrast-enhanced T1WI showing that the lesion was ring-enhancing (white arrows) and significant enhancement of the bilateral temporal leptomeningeal (white triangle). (E) T2WI FLAIR image showing that the right subependymal lesion (arrow) was smaller than that in (C), and the right basal ganglia and right temporal lobe were patchy and line-like hyperintensity (green triangles). (F) Contrast-enhanced T1WI showing that the lesion in the right subependymal was smaller than that in (D) (white arrow), the lesion in the right basal ganglia was slightly enhanced (green triangle), and the meninges were thicker as before (white triangle). (G) T2WI FLAIR image showing that the subependymal lesion had basically disappeared (white arrow), the right basal ganglia lesion was slightly smaller (green triangle), and softening could be seen inside ( ).
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F2
Brain MRI was normal, but chest CT images revealed that the upper lobe of both lungs had lesions secondary to tuberculosis, and the left pleura was thickened and had encapsulated effusion (Figures 2A,B). MTB complex DNA assay; however, the modified acid-fast staining and metagenomic next-generation sequencing (mNGS) result was negative. Moreover, MRI showed nodules and ring enhancement in the right lateral ventricle, left temporal and left cerebellar hemisphere, abnormal signal foci were observed in the right temporal lobe and basal ganglia, as well as enhancement of the pia mater of the right frontotemporal area (Figures 2C,D). Nevertheless, the lesion in the right basal ganglia was larger than before, new lesions appeared in the right pontine and right-sided temporal lobe, and the right frontotemporal leptomeninges showed more evident enhancement than before (Figures 2E,F). The lesions on the CT chest and brain MRI (Figure 2G) showed evident improvements.