Unusual reason of spinal cord infarction: tuberculous meningitis

Excerpt

A 40-year-old man was admitted with fever, chills, altered mental status, nausea and vomiting. Physical examination revealed Glasgow Coma Scale of 12 points and there was evidence of meningism, including neck rigidity. Also, left paresthesia and numbness were detected. There was no urinary or bowel retention. Magnetic resonance imaging (MRI) of the brain showed meningeal enhancements around the bilateral middle cerebral artery and anterior cerebellar artery suggesting basal meningitis. Also, enhancing lesions were observed in the white matter, right basal ganglia, cerebellum and brain stem consistent with tuberculoma (Fig. 1). There were also leptomeningeal enhancements in the thoracic region. Lumbar puncture was performed and in cerebrospinal fluid (CSF) analysis, the following results were obtained: glucose level, 34 mg/dL (normal range, 45–80 mg/dL); protein level, 275 mg/dL (normal range, 15–145 mg/dL); white blood cell count, 20/mm³; and lymphocyte count was 39 %. The results were suggestive of tuberculous meningitis and anti-tuberculosis therapy was started, including isoniazid, rifampicin, pyrazinamide, and ethambutol. CSF culture yielded Mycobacterium tuberculosis and diagnosis of tuberculosis was finalized. During follow-up, paraplegia occurred in the patient and control MRI was requested. In the control MRI of the thoracic spine, diffuse thickening and signal changes in the posterior segment of the spinal cord were observed (Fig. 2). In addition, diffusion-weighted imaging observed restricted diffusion in spinal cord (Fig. 3). The results were consistent with spinal infarction.

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