Presentation
Patient with seizures, headache, progressive hearing loss, decreased visual acuity, nasal speech, fluid dysphagia.
Patient Data
MRI shows a significant Infra and supratentorial increase of the cerebrospinal fluid signal intensity on FLAIR images, located at the level of the Sylvium fissure, bilaterally.
Leptomeningeal enhancement at the administration of gadolinium, predominantly in basal cisterns, also in suprasellar cisterna, cistern of the lamina terminalis, prepontine and pontine cisterns, apparently extended to the spinal canal portion.
Hypointense on T1 and T2, and there is an alteration in signal intensity on the FLAIR sequence, without blooming or other magnetic susceptibility artifacts.
Not restricted diffusion.
This patient was diagnosed with chronic pulmonary tuberculosis, and the diagnosis of tuberculous meningitis was made based on lumbar puncture cerebrospinal fluid culture, which confirmed the presence of Mycobacterium tuberculosis, the culture was performed by other institution and as such documented results are not available. The patient was treated with antiphymics, antimychotics with gradual improvement. Then began showing neurological symptoms deterioration of acute onset, with the suspect of spread of the underlying pathology, an MRI was performed to confirm.
Case Discussion
Tuberculous meningitis is the most common form of central nervous system tuberculosis. It is associated with a high frequency of neurologic sequelae and mortality. Vision impairment and blindness are complications in patients with tuberculous meningitis. The common causes of vision involvement include opticochiasmatic arachnoiditis, third ventricular compression of optic chiasma, optic nerve granuloma, and etambutol toxicity. Also, sensorineuronal hearing loss is related to bacterial meningitis due to inflammation or granulomatous involvement of the temporal bones.
This patient unilateral hearing loss, visual impairment, vomiting and headache was attributed to increased intracranial pressure, and based on the previous diagnosis of tuberculosis, suspicion of associated meningitis was the most likely diagnosis.
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