Case
A 72-year-old previously healthy man with a medical history of
hypertension was hospitalized with fever and confusion. His Glasgow Coma
Scale score at the visit was 6 (total score: 15), and a physical
examination revealed neck stiffness. Chest computed tomography (CT)
images revealed diffuse granules in the lungs, suggesting miliary
tuberculosis. Cerebrospinal fluid (CSF) analysis showed elevated levels
of cell count (58 /μL), protein (374 mg/dL), and adenosine deaminase
(17 U/L), with low glucose levels (32 mg/dL; serum glucose level at
169 mg/dL). Culture and PCR testing for Mycobacterium
tuberculosis in the CSF provided negative results, while sputum testing
showed a positive result. Contrast-enhanced magnetic resonance imaging
(MRI) of the patient’s head revealed meningeal enhancement from the
basilar portion of the cerebrum to the Sylvian fissure and multiple
infarctions at the corpus callosum, cerebral white matter, and
cerebellar hemisphere (Figure 1) . The patient was diagnosed
with miliary tuberculosis and tuberculous meningitis (TBM), was
administered anti-tuberculosis
agents along with systemic corticosteroid therapy, and finally survived
with dysphagia and dysarthria as sequelae.
TBM is the most severe form of extrapulmonary tuberculosis,
resulting in high mortality and
neurological sequelae. MRI is superior to CT for diagnosing TBM because
it detects typical findings such as meningeal enhancement, particularly
at the basilar meninges and the Sylvian fissure [1], tuberculomas,
hydrocephalus, and vasculitis-related infarction at the Circle of Willis
[2]. Tuberculosis is still endemic in Japan [3], and TBM should
be listed as a differential diagnosis for patients with disturbed
consciousness.