A previously healthy 10-year-old girl presented to our emergency department with a history of back pain, fever, and night sweats for 4-month duration associated with progressive walking difficulty and back deformity over the last 2 months. Physical examination revealed middle back swelling with kyphotic (gibbus) deformity. Neurological examination revealed grade 4/5 motor weakness in both lower extremities with normal deep tendon reflexes and sensations. There was no evidence of cranial nerve involvement, meningeal irritation, or cerebellar dysfunction. Laboratory tests showed a normal complete blood count, elevated C-reactive protein of 81 mg/dl, and erythrocyte sedimentation rate of 111 mm/h. Serology testing for HIV was negative. Her Mantoux test was positive of 25 mm although there was no history suggestive of tuberculosis in the family. Chest X-ray was normal; however, spine X-ray demonstrated destruction of the thoracic vertebra (T11) body and inferior end plate of the T10 vertebra with loss of disk spaces between T10, T11, and T12 (). The contrasted magnetic resonance imaging (MRI) of her spine showed kyphotic destruction of thoracic vertebrae T10, T11, and T12 with abnormal high signal on T2 and low signal on T1 in addition to a large heterogeneous multiloculated prevertabral and paraspinal abscess extending from T7 through T12 with a peripheral thick wall that had low T2 and high T1 signal with intense enhancement. These are associated with an epidural collection and retropulsed collapsed T11, which result in complete attenuation of the anterior subarachnoid spaces and compression of the distal cord (). She underwent open surgical drainage of the paravertebral abscess and posterior spine fixation from T6 to L2 with pedicle screws. During surgery, a massive purulent fluid was discharged, and biopsy from the bone and soft tissue was taken and sent for microbiological examination and cultures including Mycobacterium tuberculosis. Both acid-fast staining and mycobacterial polymerase chain reaction were negative. Histopathology examination revealed caseating granulomatous inflammation consistent with tuberculosis. Based on radiological and histopathological findings, Pott's disease was highly suspected; therefore, the decision was made to start the patient on four anti-TB drug therapy of isoniazid, rifampicin, pyrazinamide, and ethambutol) while waiting for the final result of the mycobacterial culture. Ophthalmology team was consulted for baseline eye examination before starting ethambutol, and incidentally, bilateral papilledema was detected during fundus examination. Consequently, MRI of the brain showed multiple brain lesions in the left cerebellar hemisphere, left superior temporal gyrus, and right occipital lobe (). The lesions show a ring enhancement with a hypointense center mildly surrounded by a hyperintense area, most likely represent vasogenic edema which is highly suggestive of brain tuberculomas. There was no leptomeningeal enhancement suggestive of meningitis. After four weeks, her tissue culture grew Mycobacterium tuberculosis. The patient was treated with four antituberculous drug regimen for 2-month duration, followed by additional 10 months of isoniazid and rifampicin. Oral prednisone was given initially at a dose of 2 mg/kg/day for 4 weeks and tapped gradually over the next 6 weeks. In a three-year follow-up, the patient had normal neurological examination, and her brain MRI showed complete resolution of the tuberculomas.
The patient was a 12-year-old boy, with history of sputum-positive pulmonary tuberculosis for which he was already on anti-tubercular treatment for 3 months. He presented to us with an episode of generalized seizure which had been preceded by isolated right sixth nerve palsy, episodes of seizures and gradual onset, progressive quadriparesis over the past 1 month. On examination, he had postictal confusion. Fundus examination revealed papilledema. He had a grade 3–4/5 spastic quadriparesis.\nA magnetic resonance imaging (MRI) of the brain revealed multi-lobar tuberculomas of the brain with lesions in the brainstem and cerebellum []. MRI of the spine revealed cervical (C2–3, C7–D1), dorsal (D7, D10, D11–12) and lumbar (D12–L1 including conus medullaris), multiple homogeneous enhancing oval lesions []. Only a few lesions showed characteristic ring enhancement. Mantoux was positive (15 mm induration at 48 h) and tuberculosis-interferon-γ-release-assays (Quantiferon Tuberculosis Gold In-Tube) test were positive. Erythrocyte sedimentation rate (ESR) was 40 and serology for HIV was negative. The patient was continued anti-tubercular treatment and was supplemented with steroids for about a month. The boy showed gradual but definite clinical improvement by the time of discharge 7 days later. At 3 month follow-up, he was ambulant without support. Follow-up MRI of the brain and spine revealed reduction in the enhancement of the lesions with definite ring enhancing pattern now discernable [Figure –]. Complete resolution of lesions on the last follow-up at the 8th month of treatment was seen [Figure –] and clinically he was ambulant with improvement in his VIth nerve palsy. We decided to continue anti-tubercular treatment for 18 months and the end of which he was free from any neurological deficits and back to productive life.