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Multiple lesions on CT brain scan: tuberculosis or neurocysticercosis?

Anuradha Bose¹, Jolly Chandran², Rekha Cherian³

¹ Department of Community Health , Christian Medical College, Vellore, India, 632002, India
² Department of Paediatrics, Christian Medical College, Vellore, Tamil Nadu, 632002, India
³ Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, 632004, India

Correspondence to:
abose{at}cmcvellore.ac.in

An 8-year-old girl with miliary tuberculosis, receiving appropriate treatment, presented with clinical features suggestive of increased intracranial pressure. She tested positive with the highly sensitive and specific¹ enzyme-linked immunoelectrotransfer blot assay for cysticercosis.

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Contrast enhanced computed tomography (CT) scan of the brain showed numerous, well defined, nodular and ring enhancing lesions (figs 1 and 2). These varied in shape and ranged from 3–11 mm, some with considerable peri-lesional oedema. The lesions were more extensive supratentorially (particularly at the grey–white junction of the cerebral hemispheres). No infarcts were seen. Areas of increased meningeal and perivascular enhancement were present. The ventricular system was normal.

View this figure (118K): in this window | in a new window | PowerPoint for Teaching   Figure 1 Contrast enhanced computed tomography (CT) brain scan showing numerous, subcentimetre, nodular enhancing lesions.

 

View this figure (74K): in this window | in a new window | PowerPoint for Teaching   Figure 2 Contrast enhanced CT brain scan showing nodular and irregular enhancing lesions with surrounding oedema in the high frontal region.

 

In the latest criteria by Del Brutto et al only cystic lesions showing scolices have been considered as the absolute diagnostic criterion for neurocysticercosis (NCC).² Multiple, small, circumscribed, non-enhancing cystic lesions even without the evidence of scolex do not allow for any possibility other than NCC, so this point may be included as an absolute criterion. The scolex is visualised as a bright extramural nodule within the cyst and is better demonstrated on magnetic resonance imaging. CT is less sensitive for demonstrating the scolex. Where cost is a consideration, as in this case, a better diagnostic criterion would be the demonstration of multiple, small non-enhancing cystic lesions, for which imaging with the less expensive CT scan is sufficient.

The findings on this CT scan, which favour tuberculosis over NCC, are the irregularity of the shape of some of the nodular lesions, varying enhancement patterns, considerable peri-lesional oedema, and increased meningeal perivascular enhancement.³ The girl recovered fully with continued anti-tuberculous treatment and supplemental steroids.

We gratefully acknowledge the assistance of Mrs Sumithra for her input and Mr Damodaran for his help in submission of the case report (Dept of Community Health, Christian Medical College.) We thank the patient’s mother for her consent and her willingness to share her daughter’s images.

Competing interests: None.

Patient consent: Patient/guardian consent was obtained for publication

1. Tsang, VC, Brand, JA, & Boyer, AE. An enzyme-linked immunoelectrotransfer blot assay and glycoprotein antigens for diagnosing human cysticercosis (Taenia solium). J Infect Dis 1989; 159: 50–9.[Medline]
2. Del Brutto, OH, Rajshekhar, V, White, AC, Jr, et al. Proposed diagnostic criteria for neurocysticercosis. Neurology 2001; 57: 177–83.[Abstract/Free Full Text]
3. Wasay, M, Kheleani, BA, Moolani, MK, et al. Brain CT and MRI findings in 100 consecutive patients with intracranial tuberculoma. J Neuroimaging 2003; 13: 240–7.[CrossRef][Medline]

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