1. Miliary TB Meningitis: MRI Findings in Three Patients
1Kartikasalwah Abd Latif, 1Mohd Nazri MN, 2Sobri Muda
1Department of Diagnostic Imaging, Kuala Lumpur Hospital, Malaysia
2Department of Radiology, National University of Malaysia Medical Centre, Kuala Lumpur, Malaysia

2. INTRODUCTION
Tuberculosis of the central nervous system (CNS) is one of the most serious form of infection caused by Mycobacterium tuberculosis
It is associated with significant morbidity and mortality.
Increase in immunodeficiency state from various cases is an important contributing factors.
MRI with gadolinium enhancement, is the preferred imaging tool for investigation of CNS tuberculosis:- to differentiate it from other diagnoses and for surveillance during treatment.
A. Be1, Kwang Sik Kim2, William R. Bishai1 and Sanjay K. Jain-Current Molecular Medicine 2009, 9, ,G.Alistair Lammie, Richard H.Hewlett, Johan f.Schoeman, Peter R.Donald .-Journal of Infection S 2009 , 59, ,Richa TRivedi, sona Saksena, Rakesh K Gupta – Indian Journal Imaging Nov 2009, Vol 19,issue, , Pieter Janse van Rensburg, Savvas Andronikou ,Ronald van Toorn, Manana Pienaar-PediatrRadiol (2008) 38:1306–1313, JLS Khoo,1 KY Lau,1 CM Cheung,2 TH Tsoi2-J HK Coll Radiol 2003;6:

3. CNS TUBERCULOSIS
Findings on imaging include space occupying lesion(tuberculomas or abscess), abnormal meningeal enhancement , hydrocephalus and vascular complication
Brain tuberculoma, may be single or multiple or miliary in distribution, varying in sizes ranging from 1mm to 8cm
Lesions are called miliary if size is < 2 mm in diameter.
Parenchymal miliary TB is usually associated with TB meningitis

4. CASE 1
37 years old businessman whom was previously healthy, presented with one month history of malaise; two weeks history of unsteady gait and scanning speech.
Clinical examination found cerebellar and pyramidal signs with left sided hemiparesis, power of 3/5.

5. 1st MR brain Coronal contrast T1WI Sagittal contrast T1WI
Miliary leptomeningeal nodules in the subenpendyma area, cerebellar folia and within the sulci

6. 1st MR Brain (Axial contrast T1WI)
Miliary leptomeningeal nodules within the sulci both parietal region

7. 2nd MR Brain 2 weeks later (Axial contrast T1WI)
Miliary nodules in the hemispheric parenchyma
( deep parenchymal location )

8. 2nd MR Brain 2 weeks later (Axial contrast T1WI)
Miliary leptomeningeal and parenchymal nodules,
Few larger nodules (leptomeningeal tuberculomas) were seen

9. 2nd MR Brain 2 weeks later (Gradient Echo Sequence)
Axial GRE Sequence showed punctate microhemorrhages

10. CHEST RADIOGRAPH & CT-LUNG WINDOW
AP Chest X ray showed diffuse bilateral alveolar opacity and CT showed nodules of varying sizes including miliary nodules .

11. CASE 2
47 year old lady, who was on chemotherapy for Diffuse Large B Cell Lymphoma(DBCL), developed acute delirious symptoms.
She had history of necrotising fascitis of her right eye
Clinical examination found left sided hemiparesis

12. 1st MR Brain (Axial & coronal contrast T1WI)
Enhancement of leptomeninges at the cerebelllar folia,
larger heterogenously enhancing lesions in right basal ganglia

13. 1st MR Brain (Gradient Echo Sequence)
Axial GRE Sequence showed punctate microhemorrhages

14. 2nd MR Brain 3 weeks later (Axial contrast T1WI)
Increasing miliary parenchymal nodules,
leptomeningeal nodules were more confluent

15. 2nd MR Brain 3 weeks later Coronal contrast T1WI
Sagittal contrast T1WI
Increasing of milliary nodules in the hemispheric parenchymal ( deep parenchymal location )

16. CASE 3 A 20 year old male, presented with abnormal behaviour
This was preceded by two weeks history of cough, fever and headache.
He also complained of loss of weight and loss of appetite.
Neurological examination showed evidence of lower limbs weakness, left side with power of 0/5 and right side with power of 3/5
There was associated left seventh cranial nerve palsy.

17. CT BRAIN (contrast)
Enhancement in the right basal ganglia and left occipital horn region .

18. 1st MR Brain (Axial contrast T1WI)
Nodular enhancement of leptomeninges in the temporal horn, interpeduncular , prepontine and left choroid plexus areas. Miliary parenchymal and leptomeningeal nodules in over the right parietal

19. 2nd MR Brain 3 months later (Axial contrast T1WI)
Leptomeninges enhancement were more confluent with thick intense enhancement of basal cisterns, anterior hemispheric and sylvian fissures. Miliary leptomeningeal nodules at parietal region.

20. 2nd MR Brain 3 months later
Coronal contrast T1WI
Sagittal contrast T1WI
Nodular enhancement of leptomeninges and miliary leptomeningeal nodules

21. Cranio-spinal meningeal extension
MR cervical Sagittal contrast T1WI
thick intense meningeal enhancement at prepontine, over the cerebellum, surrounding brainstem at foramen magnum and meningeal of cervical spinal cord

22. 2nd CT Brain ( 3 months later)
Cerebral infarct
1st CT Brain
2nd CT Brain ( 3 months later)
Acute right internal capsule infarction
Old right internal capsule infarction

23. Milliary pattern in both lung fields
Chest radiograph
Milliary pattern in both lung fields

24. Summary (clinical) Case #1 Case #2 Case #3 Age (year) /Gender 37/Male
47/Female
20/Male
Constitutional symptoms + -
Altered mental state
Focal neurological signs
Cranial nerve palsy
Pre-existing medical condition
malignancy
Hepatitis B
Chest XR suggestive of pulmonary TB
N/A
CSF analysis changes
Lympocystic pleocytosis, ↑protein, ↓glucose, ↓Cl-
Positive M. tuberculosis microscopy
Bronchoalveolar lavage fluid
CSF
Sputum
Outcome
Died
Defaulted

25. Summary (MRI findings)
Case #1
Case #2
Case #3
Miliary nodules
distribution
Leptomeningeal ++ +
+++
Deep parenchymal
Tuberculoma ( >2mm)
Abnormal meningeal enhancement
Vasculopathy
Micro
hemorrhages -
Infarction
Hydrocephalus
Abscess
Cranio-spinal meningeal enhancement

26. CONCLUSION
Early diagnosis of CNS TB remains challenging due to the insidious onset of nonspecific symptoms.
A high index of suspicion in the appropriate clinical setting may promote early diagnosis and treatment that can prevent unnecessary morbidity and mortality
MRI is an excellent tool to evaluate patients with suspected CNS TB
Miliary nodules (parenchymal and leptomeningeal) is one of the presenting pattern for CNS TB that need to be recognized
Parenchymal miliary TB is usually associated with TB meningitis

27. THANK YOU