Images in Clinical Medicine
Kim Eagle, M.D., Editor
Miliary Tuberculosis Involving the Central Nervous System
N Engl J Med 1996; 334:769March 21, 1996
- Article
Figure 1 A 28-year-old woman with a 10-year history of systemic lupus erythematosus presented with fever, back pain, and bilateral paresthesias and weakness of the legs of 10 days' duration. She had been taking prednisone for the preceding nine months for the management of flares. On examination her neck was supple. She had decreased power and sensation in her legs, with diminished knee and ankle reflexes, an extensor right-plantar response, and an equivocal left-plantar response. T1-weighted magnetic resonance imaging after the administration of contrast medium revealed an enhancing lesion within the spinal cord at the T11 level (Panel A) and multiple enhancing lesions at the junction of the cerebrum and cerebellum (Panel B). Lumbar puncture revealed a glucose concentration below 20 mg per deciliter (1.1 mmol per liter), a protein concentration of 92 mg per deciliter, a red-cell count of 13 per high-power field, and a white-cell count of 227 per high-power field (differential count, 88 percent segmented neutrophils and 12 percent lymphocytes). Culture of cerebrospinal fluid was positive for a strain of Myobacterium tuberculosis that was not resistant to multiple drugs. Bacterial, fungal, and viral cultures of blood and antigen tests for these agents were negative. An x-ray film and computed tomographic scan of the chest showed multiple miliary nodules. Bronchoscopic biopsy revealed caseating granulomata containing acid-fast bacilli. Culture of this tissue was also positive for M. tuberculosis.
The patient was treated with ethambutol, rifampin, isoniazid, and pyrazinamide, and tapering doses of prednisone. Repeated magnetic resonance imaging one month later revealed a reduction in the size, level of enhancement, and conspicuousness of the brain and spinal cord lesions. On subsequent clinic visits, the patient's condition improved, but the weakness of the legs persisted.
Kim Eagle, M.D.
Kieran Murphy, M.B., B.Ch.
James A. Brunberg, M.D.
University of Michigan, Ann Arbor, MI 48109-0030
