Neuroimaging of Tuberculous Myelitis: Analysis of Ten Cases and Review of Literature

It Looks Like a Spinal Cord Tumor but It Is Not

Differentiating neoplastic from non-neoplastic spinal cord pathologies may be challenging due to overlapping clinical and radiological features. Spinal cord tumors, which comprise only 2-4% of central nervous system tumors, are rarer than non-tumoral myelopathies of inflammatory, vascular, or infectious origins. The risk of neurological deterioration and the high rate of false negatives or misdiagnoses associated with spinal cord biopsies require a cautious approach. Facing a spinal cord lesion, prioritizing more common non-surgical myelopathies in differential diagnoses is essential. A comprehensive radiological diagnostic approach is mandatory to identify spinal cord tumor mimics. The diagnostic process involves a multi-step approach: detecting lesions primarily using MRI techniques, precise localization of lesions, assessing lesion signal intensity characteristics, and searching for potentially associated anomalies at spinal cord and cerebral MRI. This review aims to delineate the radiological diagnostic approach for spinal cord lesions that may mimic tumors and briefly highlight the primary pathologies behind these lesions.

Isolated Tuberculous Transverse Myelitis Without Meningitis Among Patients With AIDS: A Case Report

Acute transverse myelitis is an inflammatory disorder of the spinal cord, characterized by acute or subacute onset of paraparesis, bilateral sensory deficit, and impaired urinary bladder and sphincter tone function. Mycobacterium tuberculosis, a very rare cause of transverse myelitis, especially tuberculous myelitis without meningitis, is extremely rare. The main etiologic mechanism consists of an abnormal activation of the immune system against the spinal cord as well as the direct invasion by the bacillus. We present a 30-year-old Thai woman with AIDS, presenting with paraplegia for two days. Her MRI of the whole spine showed nodular enhancing intramedullary lesions involving the spinal cord at the T11-T12 level, and intramedullary enhancing lesion along the T12 spinal cord to the conus medullaris. Cerebrospinal fluid (CSF) examination revealed only a few white blood cells without hypoglycorrhachia or elevated CSF protein. CSF polymerase chain reaction (PCR) and culture for M. tuberculosis produced negative results. Other investigations did not demonstrate other organ involvement. Spinal cord biopsy at T12 was performed and exhibited diffuse epithelioid histiocytic proliferation admixed with small lymphocytes and plasma cells with numerous acid-fast bacilli (AFB)-positive bacilli organisms. PCR for M. tuberculosis was also detected in spinal cord tissue. Thus, acute transverse myelitis caused by isolated tuberculous myelitis without meningeal involvement was diagnosed. She had marked clinical improvement and neurologic recovery after treatment with anti-tuberculosis and intravenous steroid pulses. Isolated M. tuberculosis spinal tuberculous myelitis without meningitis is exceptionally uncommon and should be carefully considered, particularly in severely immunocompromised individuals residing in regions with a high tuberculosis burden.

Imaging recommendations and algorithms for pediatric tuberculosis: part 2-extrathoracic tuberculosis

Despite advances in diagnosis and treatment in recent years, tuberculosis (TB) remains a global health concern. Children are amongst the most vulnerable groups affected by this disease. Although TB primarily involves the lungs and mediastinal lymph nodes, it can affect virtually any organ system of the body. Along with clinical history combined with physical examination and laboratory tests, various medical imaging tools help establish the diagnosis. Medical imaging tests are also helpful for follow-up during therapy, to assess complications and exclude other underlying pathologies. This article aims to discuss the utility, strengths and limitations of medical imaging tools in the evaluation of suspected extrathoracic TB in the pediatric population. Imaging recommendations for the diagnosis will be presented along with practical and evidence-based imaging algorithms to serve as a guide for both radiologists and clinicians.

Presumptive isolated neurosarcoidosis involving eloquent structures: An argument for empirical TNF-α inhibition

There are clinical and radiological phenotypes characteristic of neurosarcoidosis. Histopathologic confirmation is preferred, however, biopsy is associated with a significant risk of morbidity when only eloquent neural structures are involved and where there is no systemic disease. We present a series of patients with isolated neurosarcoidosis and suggest circumstances where an empirical, closely monitored, trial of tumour-necrosis-factor-alpha inhibitor therapy can improve outcome and diagnostic confidence.

Tuberculous myelitis: a prospective follow-up study

Background

Prospective studies regarding tuberculous myelitis are lacking. We aimed to prospectively evaluate patients with tuberculous myelitis to identify the features that distinguish tuberculous myelitis from other myelitis.

Methods

This was a prospective study. Patients presenting with paraparesis/quadriparesis, and MRI showing myelitis were included. All patients were subjected to clinical, neuroimaging, and laboratory evaluation. Diagnosis of definite tuberculous myelitis was made if GeneXpert test in CSF was positive. Probable tuberculous myelitis was diagnosed if there was evidence of tuberculosis elsewhere in the body. Patients were treated with methylprednisolone and antituberculosis treatment. Patients were followed for 6 months. We compared the clinical, laboratory, and neuroimaging parameters and response to treatment of tuberculous myelitis with other myelitis. P values were adjusted using the Benjamini-Hochberg (BH) procedure to control false discovery rate.

Results

We enrolled 52 patients. Eighteen (34.6%) patients had tuberculous myelitis. Headache (P = 0.018) was significantly more common in tuberculous myelitis. The CSF protein (P < 0.001), and CSF cell count (P < 0.001) were significantly higher in tuberculous myelitis. On neuroimaging, a LETM was common in tuberculous myelitis. Spinal meningeal enhancement (14; 77.8%), extra-axial collection, and CSF loculation (6; 33.4%), arachnoiditis (3;16.7%), and concomitant spinal tuberculoma (2;11.1%) were other common imaging features of tuberculous myelitis. Tuberculous myelitis patients showed a better response (P = 0.025) to treatment.

Conclusion

Tuberculous myelitis was seen in approximately 35% of all myelitis cases, in a high tuberculosis endemic zone. Headache, markedly elevated CSF protein and spinal meningeal enhancement were distinguishing features. Tuberculous myelitis patients responded well to corticosteroids.

Myelitis: A Common Complication of Tuberculous Meningitis Predicting Poor Outcome

Background

Myelitis is an important complication in patients with tuberculous meningitis (TBM). However, a paucity of publications exists on the spectrum of neurological and MRI findings of TBM-related myelitis. The risk factors and prognosis of myelitis in patients with TBM are not fully understood. Therefore, this study aims to identify the risk factors, clinicoradiological features, and prognostic impact of myelitis for patients with TBM.

Methods

We conducted a retrospective study in our institution. Patients with TBM who were consecutively admitted during the period of August 2015 to December 2019 were included. We reviewed the demographic characteristics, clinical, laboratory and MRI findings, and clinical outcomes of all of the included patients. The diagnosis of myelitis was identified by a hyperintensity on T2-weighted images that were associated with cord edema, enlargement, and marginal or no enhancement on contrast-enhanced images.

Results

A total of 114 patients were included. Myelitis occurred in 19 (16.7%) patients, five of whom paradoxically developed myelitis. The common clinical signs of myelitis were paraparesis (738.9%), quadriparesis (844.4%), urinary retention or constipation (1,477.8%), and paresthesias in the lower limbs (1,052.6%). In the MRI findings, the hyperintensities on T2-weighted images involved more than 3 spinal cord segments. Myelitis was often combined with other forms of spinal cord injury, including 10 patients (52.6%) with spinal meningeal enhancement, 7 patients (36.8%) with enlargement of the central canal of the spinal cord, 6 patients (31.6%) with tuberculoma, and 4 patients (21.1%) with arachnoiditis and 1 patient (5.3%) with cerebrospinal fluid (CSF) loculations. None of the 5 patients with paradoxical myelitis were complicated with spinal meningeal enhancement and arachnoiditis, while 4 patients were complicated with enlargements of the central canal of the spinal cord. In multivariable analysis, a grade III disease severity on admission [p = 0.003, odds ratio (OR) = 8.131, 95% CI: 2.080-31.779] and high CSF protein (p = 0.033, OR = 1.698, 95% CI: 1.043-2.763) were independent risk factors for myelitis. After the 6 months follow-up, myelitis (p = 0.030, OR = 13.297, 95% CI: 1.283-137.812) and disturbance of consciousness (p = 0.042, OR = 12.625, 95% CI: 1.092-145.903) were independent risk factors for poor outcomes.

Conclusion

Myelitis was a common complication of TBM and independently predicted a poor outcome. A grade III disease severity and high CSF protein on admission were independent risk factors for myelitis. Paradoxical myelitis was rarely complicated with spinal meningeal enhancements and arachnoiditis, indicating that the immune reaction may play a dominant role.

Pott's paraplegia and role of neuroimaging in resource limited setting: A case report and brief review of the literatures

BACKGROUND

Tuberculosis (TB) is the leading cause of morbidity and mortality in low and middle income countries (LMIC). Approximately 50% of cases of skeletal TB involve the spine. Failure to identify and treat these areas of involvement at an early stage may lead to serious complications such as vertebral collapse, spinal compression, and spinal deformity. The clinical and radiologic features of Pott's disease may mimic other spine diseases such as, metastatic lesions and other infectious etiologies, this is especially imperative in older patients.

CASE REPORT

We report a 60-year-old right handed male patient presented with back pain, paraparesis, and sensory symptoms 2 weeks duration. He has history of dry cough, fatigue, and reduced appetite, but no history of weight loss, fever, night sweat, and bowel/bladder incontinence. No contact history with TB patients. He has a borderline hypertension and diabetes mellitus. Serology for HIV was negative. Thoraco-lumbar magnetic resonance image (MRI) showed destruction of L2 and L3 vertebral body and the inter-vertebral disc; with T2 hyper and T1 hypointensity of the affected vertebral bodies. Probable tuberculous spondylitis with paraparesis was considered and the patient was initiated on antituberculous regimen and short course steroid therapy. After five months treatment, the patient showed significant clinical and radiological improvement.

CONCLUSION

In summary, the present case describes, a patient with Pott's paraplegia due to probable spine tuberculosis and showed significant clinical and radiological improvement following initiation of antituberculous drugs and short course of steroid; indicating the crucial role of imaging in the diagnosis of TB, especially in resource limited settings.

Etiological and Radiological Spectrum of Longitudinal Myelitis: A Hospital-Based Study in North East India

Introduction  An inflammatory lesion of the spinal cord where three or more than three vertebral segments of the cord is involved is called longitudinal extensive myelitis (LETM). It has several varied causes out of which neuromyelitis optica (NMO) and its spectrum disorder have received a distinct entity. Various radiological and clinical features help us to suspect an etiology which then further guides us into the treatment protocol and prognosis of the patients.

Materials and Methods  A retrospective study performed in a referral center in North East India in 15 months. Thirty-two patients of LETM were enrolled based on clinical and radiological available data. An attempt was made to classify the various etiologies and correlate with their radiological findings.

Results  The most common etiology noted was NMO seen in 7 patients (21.8%) followed by tuberculosis (TB) (18.7%) and post-infection myelitis (18.7%). Other etiology seen was acute disseminated encephalomyelitis (6.24%), spinal cord infarct (3.12%), radiation myelitis (6.24%), Japanese encephalitis sequalae (3.12%), systemic lupus erythematosus (3.12%), and remained undiagnosed in six patients (18.7%). Radiologically, cervico-dorsal spine was most common location in NMO (71%) whereas dorsolumbar in TB (50%). The lesion was predominantly central in both NMO (100%) and TB (80%) as compared with the other causes of LETM. It was noted that more than 50% of the transverse area of the cord was involved in both NMO (71%) and TB (50%), but < 50% involvement were more common in the post-infectious and others causes of LETM.

Conclusion  LETM has a various differential diagnosis, infection need to be kept in mind while ruling out NMO. Radiological features can suggest or help differentiate the various etiologies of LETM but NMO and infection like TB almost has the same features except for a different cord site predilection.

Concurrent tuberculous transverse myelitis and asymptomatic neurosyphilis: A case report

BACKGROUND

Tuberculous myelitis is a rare manifestation of tuberculosis (TB) that is usually caused by hematogenous spread of Mycobacterium tuberculosis (MTB). Neurosyphilis is a neurological disease that occurs when Treponema pallidum invades the brain or the spinal cord. Individually, these two diseases involving the spinal cord are rare and cases of concurrent tuberculous transverse myelitis and asymptomatic neurosyphilis have seldom been reported.

CASE SUMMARY

A 56-year-old man presented with numbness and pain of both lower limbs for 2 wk and dysuria for 1 wk. Syphilis serology and cerebrospinal fluid (CSF) analysis supported the diagnosis of neurosyphilis and the patient was treated with intravenous ceftriaxone at first, but symptoms still progressed. Then, magnetic resonance images revealed multiple lesions along the cervicothoracic junction, and chest computed tomography showed a typical TB lesion. MTB DNA was detected in the CSF sample by metagenomic next-generation sequencing. Eventually the patient was diagnosed with tuberculous myelitis combined with asymptomatic neurosyphilis. Subsequently, quadruple anti-TB drug standardized therapy was empirically used and his neurological symptoms improved gradually.

CONCLUSION

Patients can have coinfection with tuberculous transverse myelitis and asymptomatic neurosyphilis. Patients with neurosyphilis should be examined for other pathogens.

Approach to Neurologic Complications in the Immunocompromised Patient

Neurologic complications are common in immunocompromised patients, including those with advanced human immunodeficiency virus, transplant recipients, and patients on immunomodulatory medications. In addition to the standard differential diagnosis, specific pathogens and other conditions unique to the immunocompromised state should be considered in the evaluation of neurologic complaints in this patient population. A thorough understanding of these considerations is critical to the inpatient neurologist in contemporary practice, as increasing numbers of patients are exposed to immunomodulatory therapies. In this review, we provide a chief complaint-based approach to the clinical presentations and diagnosis of both infectious and noninfectious complications particular to immunocompromised patients.

MRI findings in tubercular radiculomyelitis

This article aims to familiarize the reader with the MR imaging findings of tubercular radiculomyelitis (TBRM) and to identify the sources of infection. We evaluated 29 patients on a 1.5 T GE MRI in a cross-sectional study. MRI of the spine with contrast and lumbar puncture were performed in all patients. MRI brain was performed for 13 patients. The typical and atypical manifestations enlisted in this article, will enable early detection of TBRM when the clinical history is ambiguous, as TBRM can present with low backache in both retrovirus positive and negative patients.

Acute development of syringomyelia following TBM in a pediatric case

Background

Syringomyelia secondary to tuberculous meningitis (TBM) is rarely reported, and is usually a late complication. Acute development of syringomyelia following TBM is an exceedingly rare condition with only a few cases published in adults and no previous reports in children.

Case presentation

We present a case of syringomyelia as an acute complication of TBM in a 12-year-old boy despite appropriate chemotherapy. The patient developed spastic paraplegia of the lower limbs with fecal and urinary retention seventeen days after the initial symptoms of TBM. He was managed successfully with continued chemotherapy and high-dose intravenous immunoglobulin (IVIG).

Conclusions

This case reminds us that syrinx formation may be responsible for early neurological deterioration in children being managed for TBM. IVIG may be considered as an effective treatment option for this situation.

Tubercular longitudinally extensive transverse myelitis with lower motor neuron paralysis

Transverse myelitis typically extends two or less spinal segments, whereas longitudinal extensive transverse myelitis (LETM) extends three or more spinal segments in length and may occasionally span all the segments of the spinal cord. We present a case of spinal tuberculosis presenting with LETM with true lower motor neuron-type flaccid paraplegia.

Tuberculous Myelopathy Associated with Longitudinally Extensive Lesion: A Clinicoradiological Review of Reported Cases

Acute transverse myelitis is an inflammatory disorder of the spinal cord in which there is no evidence of spinal cord compression. Longitudinally extensive transverse myelitis (LETM) is a specific subtype of acute transverse myelitis that usually affects three or more vertebral levels and produces marked neurological deficits. While the most-common cause of LETM is neuromyelitis optica or neuromyelitis optica spectrum disorder, there are rare cases of other causes mimicking this condition, including tuberculosis (TB). We sought to review the clinicoradiological features of TB myelopathy associated with longitudinally extensive lesion, which may mimic LETM, in the English literature. We searched the PubMed, Google Scholar, Web of Science, and Scopus databases for relevant articles using search terms including “longitudinally extensive transverse myelitis,” “tuberculosis,” “TB spinal cord,” and various combinations of these expressions. Full-text papers were selected without limiting the publication year. We also examined the reference lists of key papers to identify further articles that are potentially relevant. We found 10 cases in 7 papers describing TB myelopathy associated with longitudinally extensive lesion. The demographics, clinical features, relevant cerebrospinal fluid findings, and radiological findings were compiled and summarized. TB myelopathy associated with longitudinally extensive lesion is very rare, with no documented prevalence. Early and accurate diagnosis is important since the condition is potentially treatable.

Spinal Tuberculosis: Clinicoradiological Findings in 274 Patients

Background

Mycobacterium tuberculosis is a major cause of myelopathy and radiculopathy in settings with a high prevalence of tuberculosis/human immunodeficiency virus (HIV) coinfection. However, a paucity of publications exists on the spectrum of neurological and magnetic resonance (MR) imaging findings of spinal tuberculosis in these populations.

Methods

We conducted a retrospective study of adults with spinal tuberculosis at a referral center in South Africa for patients with spinal disease without bony involvement seen at plain film radiography. We report the clinical, laboratory and spinal MR imaging findings, compare HIV-infected and HIV-uninfected patients, and correlate clinical and cerebrospinal fluid findings with those of MR imaging.

Results

Of 274 patients, 209 (76%) were HIV infected and 49 (18%) were HIV uninfected. Radiculomyelitis occurred in 77% (n = 210), and spondylitis in 39% (n = 106). Subdural abscess (n = 42) and intramedullary tuberculoma (n = 33) were common. In 24% of HIV-infected and 14% of HIV-uninfected patients, spinal disease manifested as a paradoxical tuberculosis reaction, frequently following tuberculous meningitis. The triad of neurological deficit, fever, and back pain was similar in patients with spondylitis (24%), epi/subdural abscess without bony disease (14%), meningoradiculitis (17%), and isolated myelitis (17%) .

Conclusions

Radiculomyelitis is a common manifestation of spinal tuberculosis in settings with high tuberculosis/HIV prevalence, often presenting as a paradoxical reaction. We describe a high frequency of rarely reported spinal tuberculosis manifestations, suggesting that these are more common than implied by the literature.

Tuberculous meningomyelitis in magnetic resonance imaging: A Chinese case report

Tuberculous meningomyelitis is a relatively rare but serious type of nervous system tuberculosis. This disease is caused by invasion of the spinal cord or the spinal meninges tuberculosis. The early symptoms are not typical and lack specificity. It can cause early changes in the MRI. Analysis of the MRI manifestations combined with the clinical manifestations and cere- brospinal fluid examination can facilitate accurate diagnosis of the disease. Early treatment has a clear effect, we want to increase knowledge of the dis- ease by sharing this case in order to reduce clinical misdiagnosis and allow more patients to be treated in time.

HIV and spinal cord disease

The epidemiology of spinal cord disease in human immunodeficiency virus (HIV) infection is largely unknown due to a paucity of data since combination antiretroviral therapy (cART). HIV mediates spinal cord injury indirectly, by immune modulation, degeneration, or associated infections and neoplasms. The pathologies vary and range from cytotoxic necrosis to demyelination and vasculitis. Control of HIV determines the differential for all neurologic presentations in infected individuals. Primary HIV-associated acute transverse myelitis, an acute inflammatory condition with pathologic similarities to HIV encephalitis, arises in early infection and at seroconversion. In contrast, HIV vacuolar myelopathy and opportunistic infections predominate in uncontrolled disease. There is systemic immune dysregulation as early as primary infection due to initial depletion of gut-associated lymphoid tissue CD4 cells and allowance of microbial translocation across the gut that never fully recovers throughout the course of HIV infection, regardless of how well controlled. The subsequent proinflammatory state may contribute to spinal cord diseases observed even after cART initiation. This chapter will highlight an array of spinal cord pathologies classified by stage of HIV infection and immune status.

Haemorrhagic conversion of infectious myelitis in an immunocompromised patient

A 28-year-old man recently diagnosed with HIV (CD4 19 cells/mm³, viral load 3.6 million copies/mL, not on highly active antiretroviral therapy on initial diagnosis at outside hospital), disseminated histoplasmosis, shingles and syphilis presented with paraplegia developing over 3 days. Spine MRI demonstrated a longitudinally extensive cord lesion extending from C3 to the tip of the conus. Brain MRI was consistent with meningoencephalitis. Cerebrospinal fluid findings were notable for positive varicella zoster virus (VZV) and cytomegalovirus (CMV) PCRs as well as a Venereal Disease Research Laboratory titre of 1:2. Patient was started on treatment for VZV and CMV meningoencephalitis, neurosyphilis and high-dose steroids for infectious myelitis. Repeat spine MRI demonstrated subacute intramedullary haemorrhage of the cervical cord. He was ultimately discharged to a skilled nursing facility for long-term intravenous antiviral therapy and rehabilitation. After 59 days in the hospital, his neurological exam remained grossly unchanged, with flaccid paraplegia and lack of sensation to fine touch in his lower extremities.

Distal cord-predominant longitudinally extensive myelitis with diffuse spinal meningitis and dural abscesses due to occult tuberculosis: A rare occurrence

Tuberculous myelitis usually involves thoracic and only rarely, distal cord. Longitudinal lesions more than three spinal segments long in tuberculosis (TB) are usually due to intramedullary tuberculomas and not infectious myelitis. We report a 17-year-old male with acute myelitis from D7 to conus medullaris, diffuse spinal meningitis, subdural and epidural abscesses, normal vertebrae, intervertebral discs, and brain imaging. Cerebrospinal fluid (CSF) showed raised proteins, lymphocytosis, hypoglycorrhagia, and positive TB-polymerase chain reaction. Chest X-ray was normal, and sputum was negative for acid-fast Bacilli. Chest computed tomography (CT) revealed endobronchial TB. The patient was successfully treated with antitubercular drugs and steroids. In endemic areas, a high index of suspicion should be kept for TB in patients with myelitis, especially those with spinal abscesses and a suggestive CSF report. In selected cases, there may be a role of CT scan inspite of normal X-ray.

Spinal cord involvement in tuberculous meningitis

OBJECTIVES

To summarize the incidence and spectrum of spinal cord-related complications in patients of tuberculous meningitis.

SETTING

Reports from multiple countries were included.

METHODS

An extensive review of the literature, published in English, was carried out using Scopus, PubMed and Google Scholar databases.

RESULTS

Tuberculous meningitis frequently affects the spinal cord and nerve roots. Initial evidence of spinal cord involvement came from post-mortem examination. Subsequent advancement in neuroimaging like conventional lumbar myelography, computed tomographic myelography and gadolinium-enhanced magnetic resonance-myelography have contributed immensely. Spinal involvement manifests in several forms, like tuberculous radiculomyelitis, spinal tuberculoma, myelitis, syringomyelia, vertebral tuberculosis and very rarely spinal tuberculous abscess. Frequently, tuberculous spinal arachnoiditis develops paradoxically. Infrequently, spinal cord involvement may even be asymptomatic. Spinal cord and spinal nerve involvement is demonstrated by diffuse enhancement of cord parenchyma, nerve roots and meninges on contrast-enhanced magnetic resonance imaging. High cerebrospinal fluid protein content is often a risk factor for arachnoiditis. The most important differential diagnosis of tuberculous arachnoiditis is meningeal carcinomatosis. Anti-tuberculosis therapy is the main stay of treatment for tuberculous meningitis. Higher doses of corticosteroids have been found effective. Surgery should be considered only when pathological confirmation is needed or there is significant spinal cord compression. The outcome in these patients has been unpredictable. Some reports observed excellent recovery and some reported unfavorable outcomes after surgical decompression and debridement.

CONCLUSIONS

Tuberculous meningitis is frequently associated with disabling spinal cord and radicular complications. Available treatment options are far from satisfactory.

Cerebral infarction and tuberculoma in central nervous system tuberculosis: frequency and prognostic implications

BACKGROUND

Tuberculoma and cerebral infarctions are serious complications of central nervous system (CNS) tuberculosis. However, there are no studies comparing prognostic value of tuberculoma and infarcts alone and in patients diagnosed with CNS tuberculosis.

OBJECTIVE

The objective of this study was to identify frequency and prognostic value of tuberculoma and cerebral infarcts in a large sample of CNS tuberculosis patients.

METHODS

Retrospective chart review of patients diagnosed with CNS tuberculosis in a tertiary care hospital in Pakistan over 10-year period was carried out.

RESULTS

There were 404 patients included in this study (mean age of 43 years). There were 209 (52%) men and 195 (48%) women. Tuberculoma were present in 202 subjects (50%) while infarcts were present in 25% patients. 147 (36%) had tuberculous meningitis (TBM) without tuberculoma or infarction on CT or MRI, 158 (39%) had TBM with intracranial tuberculomas, 60 (15%) had TBM with cerebral infarction while 39 (10%) had TBM with both tuberculoma and infarction. At discharge, 249 patients (62%) were either normal (Modified Rankin Score (MRS)=0) or mild to moderately disabled (MRS=1-3) while 82 patients (20%) had severe disability (MRS=4-5). 73 (18%) patients died (MRS=6) during hospitalisation. Using logistic regression analysis, significant predictors of poor outcome included old age, high TBM grading, presence of infarction and presence of hydrocephalus.

CONCLUSIONS

Tuberculomas were present in 50% of patients, while infarcts were present in 25%. Old age, TBM grading, presence of infarction and hydrocephalus were all predictors of poor outcome.

MRI in transverse myelitis

Transverse myelitis is an acute inflammatory disease of the spinal cord, characterized by rapid onset of bilateral neurological symptoms. Weakness, sensory disturbance, and autonomic dysfunction evolve over hours or days, most progressing to maximal clinical severity within 10 days of onset. At maximal clinical severity, half will have a paraparesis, and almost all patients have sensory disturbance and bladder dysfunction. Residual disability is divided equally between severe, moderate and minimal or none. The causes of transverse myelitis are diverse; etiologies implicated include demyelinating conditions, collagen vascular disease, and parainfectious causes, however, despite extensive diagnostic work-up many cases are considered idiopathic. Due to heterogeneity in pathogenesis, and the similarity of its clinical presentation with those of various noninflammatory myelopathies, transverse myelitis has frequently been viewed as a diagnostic dilemma. However, as targeted therapies to optimize patient outcome develop, timely identification of the underlying etiology is becoming increasingly important. In this review, we describe the imaging and clinical features of idiopathic and disease-associated transverse myelitis and its major differentials, with discussion of how MR imaging features assist in the identification of various sub-types of transverse myelitis. We will also discuss the potential for advanced MR techniques to contribute to diagnosis and prognostication.

Novel magnetic resonance imaging scoring system for diagnosis of spinal tuberculosis: A preliminary report

Background:

There exists a lot of ambiguity in the preoperative diagnosis of the various vertebral lesions. Mostly in these patients tuberculosis of spine (TB) is suspected due to endemicity of the disease in the Indian subcontinent. However, no definite guidelines are available to diagnose tuberculous (TB) vertebral lesions in the current literature.

Study Design:

This prospective study was conducted in the Department of Neurosurgery, Nizam's Institute of Medical Sciences, from August 2009 to March 2012.

Aim of the Study:

To formulate non invasive methods to diagnose tuberculous vertebral lesions confidently so that the dependency on histopathologic diagnosis can be reduced.

Material and Methods:

Spinal MRI images of 45 patients suspected of having tuberculosis aetiology were included in the study prospectively.

Results:

A total of 64 patients were analysed and 19 patients were excluded due to lack of regular follow up or histological proof. The patients were divided into two groups; those with TB of the spine and those with some other condition affecting the spine (non TB spine) based on the final diagnosis. Of the 45 patients males were 30 (66.6%) and females were 15 (33.3%). There was no significant difference in the mean age of presentation. For TB patients this was 41 ± 15.56 years and in Non TB was 43 ± 18.27 years. All patients presented with backache in either group. There was epiphyseal involvement (100%), disc height reduction (71.42%) and pedicle destruction (42.82%) in plain X-rays in the TB group. Lumbar spine was the most common affected region in our study (26.31% in non TB and 34.6% in TB group of patients). Significant P value and the Odds Ratio was found for T1 hypo intensity, T2 hyper intensity, epiphyseal involvement, disc involvement, pedicle involvement, anterior subligamentous extension, paraspinal extension and no spinous process involvement (eight parameters). The eight parameters were tested among both the groups and it was noted that scores ≥ 6 favored a tuberculous pathology whereas ≤4 were suggestive of non tuberculous etiology.

Conclusions:

The eight point MRI criteria of the vertebral lesions are likely to enhance the diagnostic ability of tuberculous and non tuberculous pathologies thereby reducing the dependency on histopathologic diagnosis or invasive method for early initiation of therapy.

Unusual presentation of tuberculosis with multiple spinal deposits

We discuss the relevant imaging of an unusual case of disseminated tuberculosis presenting with multifocal spinal deposits.

Neuroimaging in acute transverse myelitis

Transverse myelitis is an acute inflammatory condition. A relatively rare condition, the diversity of causes makes it an important diagnostic challenge. An approach to the classification and work-up standardizes diagnostic criteria and terminology to facilitate clinical research, and forms a useful tool in the clinical work-up for patients at presentation. Its pathogenesis can be grouped into four categories. Imaging appearances can be nonspecific; however, the morphology of cord involvement, enhancement pattern, and presence of coexistent abnormalities on MR imaging can provide clues as to the causes. Neuroimaging is important in identifying subgroups that may benefit from specific treatment.

Mycobacteria infection in incomplete transverse myelitis is refractory to steroids: a pilot study

Incomplete transverse myelitis (ITM) of unknown origin is associated with high rates of morbidity and mortality. This prospective, open-label study was undertaken to determine whether antituberculous treatment (ATT) might help patients with ITM whose condition continues to deteriorate despite receiving IV methylprednisolone treatment. The study consisted of 67 patients with steroid-refractory ITM in whom Mycobacterium tuberculosis (MTB) was suspected clinically and in whom other known causes of myelopathy were excluded. The study occurred from January 2003 to June 2010. Patients underwent trial chemotherapy with ATT. Efficacy was assessed by the American Spinal Injury Association (ASIA) scoring system, the Barthel Index (BI) and the Hauser Ambulation Index (AI) at baseline, 12 months, and 24 months, using magnetic resonance imaging (MRI). Of the 67 patients enrolled, 51 were assessed and 16 withdrew. At 24 months, 49 patients experienced benefits as indicated by significantly increased ASIA and BI scores. The Hauser AI index also improved with markedly decreased abnormal signals in spinal cord MRI over time. The results from this prospective study provide beneficial clinical and MRI data on the efficacy of ATT in ITM patients and suggests mycobacteria may be an important and neglected cause of myelitis.

Medical management of spinal tuberculosis: an experience from Pakistan

STUDY DESIGN

A prospective study on spinal tuberculosis conducted at Fauji Foundation Hospital, Rawalpindi, Pakistan, with 1 year of follow-up.

OBJECTIVE

The main aim was to diagnose spinal tuberculosis on clinical grounds and with simple noninvasive laboratory and radiology investigations and to treat the patients with antituberculosis drugs.

SUMMARY OF BACKGROUND DATA

Spinal tuberculosis associated with any neuro deficit is usually treated by surgery. Medical treatment can reverse most of the neuro deficit. Surgery should not be the first choice of treatment.

METHODS

Twenty-six patients with spinal tuberculosis were clinically diagnosed, were started on antituberculosis treatment, and were followed up for 12 months.

RESULTS

Backache is the most common symptom. Thirty-eight percent of patients presented with neuro deficit in the form of paraplegia and quadriplegia. Erythrocyte sedimentation rate was high in 100% cases. Plain radiograph diagnosed the disease in 88.27% patients. Eighty-five percent of cases completely improved on medical treatment without any surgical intervention.

CONCLUSION

Uncomplicated spinal tuberculosis is a medical problem. The study shows that surgical intervention is not always necessary.

British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children

SUMMARY AND KEY RECOMMENDATIONS: The aim of these guidelines is to describe a practical but evidence-based approach to the diagnosis and treatment of central nervous system tuberculosis in children and adults. We have presented guidance on tuberculous meningitis (TBM), intra-cerebral tuberculoma without meningitis, and tuberculosis affecting the spinal cord. Our key recommendations are as follows: 1. TBM is a medical emergency. Treatment delay is strongly associated with death and empirical anti-tuberculosis therapy should be started promptly in all patients in whom the diagnosis of TBM is suspected. Do not wait for microbiological or molecular diagnostic confirmation. 2. The diagnosis of TBM is best made with lumbar puncture and examination of the cerebrospinal fluid (CSF). Suspect TBM if there is a CSF leucocytosis (predominantly lymphocytes), the CSF protein is raised, and the CSF:plasma glucose is <50%. The diagnostic yield of CSF microscopy and culture for Mycobacterium tuberculosis increases with the volume of CSF submitted; repeat the lumbar puncture if the diagnosis remains uncertain. 3. Imaging is essential for the diagnosis of cerebral tuberculoma and tuberculosis involving the spinal cord, although the radiological appearances do not confirm the diagnosis. A tissue diagnosis (by histopathology and mycobacterial culture) should be attempted whenever possible, either by biopsy of the lesion itself, or through diagnostic sampling from extra-neural sites of disease e.g. lung, gastric fluid, lymph nodes, liver, bone marrow. 4. Treatment for all forms of CNS tuberculosis should consist of 4 drugs (isoniazid, rifampicin, pyrazinamide, ethambutol) for 2 months followed by 2 drugs (isoniazid, rifampicin) for at least 10 months. Adjunctive corticosteroids (either dexamethasone or prednisolone) should be given to all patients with TBM, regardless of disease severity. 5. Children with CNS tuberculosis should ideally be managed by a paediatrician with familiarity and expertise in paediatric tuberculosis or otherwise with input from a paediatric infectious diseases unit. The Children's HIV Association of UK and Ireland (CHIVA) provide further guidance on the management of HIV-infected children (www.chiva.org.uk). 6. All patients with suspected or proven tuberculosis should be offered testing for HIV infection. The principles of CNS tuberculosis diagnosis and treatment are the same for HIV infected and uninfected individuals, although HIV infection broadens the differential diagnosis and anti-retroviral treatment complicates management. Tuberculosis in HIV infected patients should be managed either within specialist units by physicians with expertise in both HIV and tuberculosis, or in a combined approach between HIV and tuberculosis experts. The co-administration of anti-retroviral and anti-tuberculosis drugs should follow guidance issued by the British HIV association (www.bhiva.org).