Patient Cases - AIDS Complicated Cerebral Tuberculosis

Case history and clinical manifestations

It is a case of AIDS definitely diagnosed by CDC, a female aged 38 years, who had history of

paid blood donations in the year of 1995. She was diagnosed as having miliaris pulmonary

tuberculosis in Apr. 2002 and had symptoms of headache, dizziness, nausea, vomiting and

low-grade fever. CD4 count was 68 cells/µl.

Imaging demonstrations

Fig. 2-6-1E

Fig. 2-6-1 A,B,C Axial MR imaging, demonstrating multiple flaky high T₁ signal in the brain and

obvious edema with unclearly-defined borders.

Fig. 2-6-1 D,E,F,G,H,I,J Axial and sagittal MR imaging, demonstrating multiple flaky high T₂

signal in the brain, cerebellum and brain stem with ring shaped slightly high T₂ signal in collar

sign, obvious edema with unclearly-defined borders.

Fig. 2-6-1K Fig. 2-6-1K

Fig. 2-6-1 K,L,M,N,O,P Contrast-enhanced axial, sagittal and coronal MR imaging,

demonstrating multiple nodular abnormal enhancement, punctiform centers with no

enhancement in same sizes with regular shapes.

Diagnosis

AIDS complicated cerebral tuberculosis.

Discussion

In patients with AIDS-related tuberculosis, occurrence of tuberculosis in central nervous system

is about 10%. It is supposed that tuberculosis of central nervous system can be attributed to

spread of bacillus tuberculosis from primary pulmonary tuberculosis foci to meninges and/or

cerebral parenchyma through blood circulation. For this case, the patient had suffered from

miliaris pulmonary tuberculosis with secondary cerebral tuberculosis. Her MR imaging

demonstrated cerebral foci of the same size with regular shape and they diffusively scattered

with some characteristic features. During acute phase, cerebral tuberculoma has

demonstrations of nodes in even density or slightly high density with unclearly-defined borders

by CT scanning and contrast-enhanced scanning demonstrates irregular ring or nodular

enhancement, mature tuberculoma with clearly-defined borders in round or oval enhancement.

It has been reported that occurrence of tuberculosis in cases of HIV infection has been

significantly increasing with pathogenesis of recessive tuberculosis developing into clinical

symptomatic tuberculosis promoted by HIV infection. The negative results of tuberculin test

found in cases of HIV infection is frequently due to HIV caused immune inhibition. Tuberculoma

frequently occurs in the early stage of HIV infection with rare nodular imaging demonstrations in

the middle and advance stages. Due to immune inhibition of the host, his/her capability of

constructing epithelial granuloma to fight against infections is impaired. Therefore, tuberculosis

can be spread with predominant manifestations of intracephalic multiple space-occupying

edema, meninges enhancement and even hydrencephalus, and sometimes deep cerebral

infarction commonly occurs in areas of perforating branches of cerebral basilar part, whose ring

or nodular enhancement is difficult to be differentiated from cerebral toxoplamosis and

lymphoma. Cerebral toxoplamosis commonly occurs in areas of cerebral basal ganglia,

cerebral cortex and medulla with different sized foci and in different shapes with helical or ring

enhancements. Lymphoma commonly occurs in singular at the location of basal ganglia that is

characteristically with flaming-liked edema and map-liked abnormal enhancement by

contrast-enhanced scanning. However, lymphoma secondary to AIDS usually demonstrates no

obvious edema with rare occurrence of flaming-liked edema.