A 66-year-old woman was admitted with bilateral lower extremity weakness and voiding difficulty for 2 weeks. Paraparesis with muscle power of the right lower extremity was grade 2/5 and the left lower extremity was grade 1/5, impaired sensations below the L1 level and decreased strength in the anal sphincter tone. Lower extremity reflexes including knee jerk and ankle jerk were absent. No evident upper extremity motor or sensory deficit was seen. Magnetic resonance imaging (MRI) of the thoracolumbar showed about 1.2×1×4 cm sized intramedullary enhancing lesion with central necrosis on conus medullaris at T12-L1 levels. The lesions were isointense on T1-weighted images and hyperintense on T2-weighted images, which were associated with diffuse edema of spinal cord on T7-T11 level. We presumed that this abscess might be closely related with tuberculous abscess. However, in laboratory, sputum, Cerebrospinal fluid (CSF) cultures and Acid-Fast bacilli stains were negative. A cerebrospinal fluid study showed glucose levels 55 mg/dL, protein 100 mg/dL, and 50 lymphocytes/mm3. Initial C-reactive protein (CRP) was 24. On review of her previous medical history, she was treated for pulmonary tuberculosis, diagnosed six months earlier. And 1 month ago, pus was found in the right kidney due to her flank pain, which was proved to be tuberculosis after drainage. She was also treated by rifampin, ethambutol, pyrazinamide at other hospital. Chest simple X-ray showed that features of bilateral pulmonary tuberculosis with multiple patchy consolidations. We took brain MRI in order to differentiate the brain lesion. MRI findings of brain showed multiple abscesses at the cerebrum and cerebellum. Results of a Tb INF-r were positive. Initially, we planed surgical treatment, however, we postponed the surgery due to her poor general condition and refusal of her family. Under the diagnosis of multiple CNS tuberculomas on spinal cord and brain, the anti-tuberculous drugs were started with rifampicin 600 mg, isoniazid 300 mg, pyrizinamide 1000 mg, ethambutol 800 mg. At 2 month later after medication, the muscle power in the both lower limbs had improved to grade 4/5, and voiding was also recovered. After 3 months of medical treatment, she could walk by herself. Follow up lab of CRP was reduced from 24 to 0.9 at 2 month later. Normalization of CRP was seen at 3 months of medication for tberculosis. After 6 months, the MRI of spine showed the markedly decreased size of intramedullary nodule at T12-L1 levels, which meaned improvement of tuberculous abscess, though perilesional edema of conus medullaris still remain. And MRI of brain showed that marked improvement of multiple nodular enhancing lesions at both frontoparietal lobe, right thalamus and both cerebellar hemisphere. Finally, we concluded these lesions were due to tuberculosis though we did not have the pathologic confirmation.
A 65-year-old female visited the emergency department, complaining about headache, paraplegia, numbness of both legs, and urinary incontinence for one week. She had a history of kidney transplantation because of a stage 5 chronic kidney disease. She was also diagnosed with active pulmonary TB two weeks ago and started taking the combination of antituberculosis medication (isoniazid, ethambutol, rifabutin, and pyridoxine). Neurologic examination revealed only a trace or a flicker of movement on both lower extremities and impaired sensations below T10 level, while the motor and sensory functions of upper extremities were normal. The anal sphincter tone was decreased, and the deep tendon reflexes were absent on both lower limbs.\nThe spine magnetic resonance imaging (MRI) showed a round, well-defined, intramedullary-enhancing lesion (7×6×14mm in size) at T9-T10 levels with high signal change of spinal cord at T5-L1 levels (). Surgical resection was performed to decompress the spinal cord. There was a noted greyish, well-demarcated, firm mass that was radically removed. Consistent with tuberculosis, the histopathologic examination showed noncaseating, granulomatous inflammation. A few acid-fast bacilli were detected in granuloma (), and the neurologic deficit was not fully recovered right after the resection. After surgery, patient complains of persistent headache, so we took brain MRI in order to differentiate the brain lesion and it revealed multiple rim-enhancing nodular lesions which were suggestive of tuberculomas (). Anti-tuberculosis medications were persisted with rehabilitation program.