Figure 2. A patient with multifocal nodular lesions diagnosed with CNS tuberculosis A patient with multifocal nodular lesions diagnosed with CNS tuberculosis.

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Figure 2. A patient with multifocal nodular lesions diagnosed with CNS tuberculosis A patient with multifocal nodular lesions diagnosed with CNS tuberculosis (A) Prebiopsy brain MRI in patient PT-8 shows multifocal subcortical and deep white matter lesions in fluid-attenuated inversion recovery (FLAIR) MRI. Several focal nodular enhancing lesions are seen in T1-weighted + gadolinium (Gad) MRI. A brain biopsy targeted a nodular lesion in the left posterior frontal-parietal region (yellow circles). Subsequent brain MRIs demonstrate a dramatic improvement of the lesions 23 days after biopsy and 15 days after instauration of the anti-TB medications. (B) Diagrammatic representation of the time profile for biopsy processing for neuropathology and next-generation sequencing (NGS) diagnosis in PD-8. Although histologic studies were able to establish the presence of a granulomatous inflammation immediately after biopsy, a more comprehensive neurohistologic analysis completed 6 days after biopsy failed to demonstrate infectious pathogens. NGS diagnosis was established 7 days after biopsy, confirming the presence of Mycobacterium tuberculosis, a finding that was used to support the treatment with antituberculous medication and ruled out the presence of Nocardia infection. (C) Histologic demonstration of granulomatous inflammation in hematoxylin & eosin stains. (D) Grocott methenamine silver stain is negative for fungal species. Similarly, Ziehl-Neelsen stain for acid-fast bacilli (E) is negative. Steven L. Salzberg et al. Neurol Neuroimmunol Neuroinflamm 2016;3:e251 © 2016 American Academy of Neurology