DX: Mycobacterial Ependymitis + Hydrocephalus / ADEM

Well this case got me really interested. First, because of the young age and acute onset of symptoms and rapid neurological changes (both clinical and imaging) that was missed or unclear on the first evaluation with the CT scan.

CT scan was normal, but as a retrospective approach you can see some irregularity on lateral ventricle walls ( c'mon with some imagination right?  hehe). Rest was unremarkable. Then patient suffered altered mental status with history of fever, so an inflamatory setting was considered. Spinal tap was made previous MR scan.

Click to enlarge:

There was periventricular white matter hyperintensities with dilated ventricular system; also noted in left cerebellar culmen and as a surrounding lineal lesion adjacent to right frontal horn of lateral ventricle. All findings are inconclusive, but the most intriguing finding was on sagital T2 images:

 Multiple focal hyperintensities of corpus callosum that can be seen in hydrocephalus as transependymal CSF mygration but those peculiar characteristics are frequently seen in Multiple Sclerosis (Dawson's fingers) and Acute Disemminated Encephalomyelitis (ADEM).

Spinal tab revealed Mycobacterium Tubelculosis. (yup)

So..let's summarize. Maybe the focal hyperintensities on cerebellum and lateral to frontal horn are tuberculomas that can provoque local irritation to ependymae (most likely on cerebellum) and hydrocephalus can be produced.

Now just a quick review on differentials:

MS in native Guatemalan's such as in this case is almost non-existent, in fact all of Leukodystrophies.  If consider, one has to include also CADASIL (cerebral autosominal dominant arteriopathy with subcortical infarcts and lekodystrophy) wich is the most common form of hereditary stroke disorder. Findings on MRI are similar but usually occur between 40 and 50 years of age, although MRI is able to detect signs of the disease years prior to clinical manifestation of disease. So is less likely but probable.

ADEM is considered to be the borderline of MS and is a good differential because can coexist with previous viral or bacterial infection. It produces multiple inflammatory lesions in the brain and spinal cord, particularly in white matter areas. Usually these are found in the subcortical and central white matter and cortical gray-white junction of both cerebral hemispheres, cerebellum and brain stem but periventricular white matter and gray matter of the cortex, thalami and basal ganglia may also be involved. Image features are variable but are present in younger populations and is a autoimmune complication of previous infection.

Thank you for your participation on this case...feel free to comment!