Tuberculous Radiculomyelitis Complicating Tuberculous Meningitis: Case Report and Review

Abstract

Tuberculous radiculomyelitis (TBRM) is a complication of tuberculous meningitis (TBM), which has been reported rarely in the modern medical literature. We describe a case of TBRM that developed in an human immunodeficiency virus (HIV)-infected patient, despite prompt antituberculous treatment. To our knowledge, this is the second case of TBRM reported in an HIV-infected patient. We also review 74 previously reported cases of TBRM. TBRM develops at various periods after TBM, even in adequately treated patients after sterilization of the cerebrospinal fluid (CSF). The most common symptoms are subacute paraparesis, radicular pain, bladder disturbance, and subsequent paralysis. CSF evaluation usually shows an active inflammatory response with a very high protein level. MRI and CT scan are critical for diagnosis, revealing loculation and obliteration of the subarachnoid space along with linear intradural enhancement. As in other forms of paradoxical reactions to antituberculous treatment, there is evidence that steroid treatment might have a beneficial effect.

Neurological and systemic complications of tuberculous meningitis and its treatment at Auckland City Hospital, New Zealand

“…Myeloradiculopathy is caused by leptomeningeal exudates encasing the spinal cord, nerve roots and blood vessels. [32][33][34][35] Impairment of venous drainage may result in spinal cord oedema, while infarction of the spinal cord may be secondary to vasculitic occlusion of a spinal artery. 33 The CSF protein concentration is often very high.…”

Tuberculosis of the central nervous system: overview of neuroradiological findings

“…There is mild fusiform cord enlargement. b Axial gadolinium-enhanced T1-weighted MR image demonstrates a focal enhancing intramedullary nodule It frequently accompanies intracranial disease and should be suspected whenever a patient with TBM develops spinal cord symptoms [4,40,43]. The thoracic cord is most commonly affected, followed by the lumbar and the cervical regions [4,15].…”

“…With time, exudates get organized and fibrin-coated nerve roots can become adherent to each other as well to the thecal sac [4,40]. The TBRM should be suspected whenever a patient with TBM develops spinal cord symptoms [43]. Although the contents of the spinal canal may be difficult to see on CT, some CT findings have been reported in TBRM, such as gross volume changes of the myelum, pear-shaped cross section in the lower thoracic region, Fig.…”

Acute paraplegia in a patient with AIDS and a normal CSF examination

“…Although in cases of tuberculous abscess, the CSF may be normal until rupture occurs into the subarachnoid space, a lymhocytosis, raised protein and possibly hypoglycorrachia would have been expected even in a treated and sterile CSF. 3 A normal CSF examination was reported in a previous study. 6 This case strongly emphasizes that the diagnosis of opportunistic tuberculosis in the setting of HIV infection can be elusive.…”

“…[1][2][3] It may arise as a primary manifestation of the infection, by downward extension of tuberculous meningitis, or by spread from a vertebral osteomyelitis. 3 It is not uncommon for it to develop during treatment for a primary infection elsewhere. 4 The clinical features of this patient were those of radiculitis followed by rapid flaccid paraparesis.…”