Purpose or Case Report: Tuberculous meningitis (TBM) causes significant morbidity and mortality in young children. Early treatment can be initiated with MR imaging diagnosis. We present MR detectable miliary meningeal TB in two patients presenting in a developed world setting.
Case 1: A 9 y/o girl of Haitian descent, developed fevers, cough, lethargy and seizures. Brain MRI demonstrated multiple, small, T2-dark, rim-enhancing lesions, associated with cranial nerve and leptomeningeal enhancement. Chest CT showed mediastinal lymphadenopathy, multiple small interstitial lung nodules and a splenic hypo enhancing lesion. CSF showed pleocytosis, low glucose, and high protein. She was started on 4-drug treatment for TBM and dexamethasone. Serial bronchoalveolar lavage was Xpert MTB/RIF and acid-fast negative. Contact tracing revealed a remote positive contact with pulmonary tuberculosis from Haiti. Endobronchial US-guided biopsy of a subcarinal lymph node was positive for Xpert MTB PCR.

Case 2: A 17 y/o female with Crohn’s disease on adalimumab developed refractory ear infections despite multiple courses of antibiotics and underwent myringotomy, with negative aerobic ear fluid culture. She had two chronic skin lesions. Brain MRI, obtained due to persistent otorrhea, showed multiple, small, round, T2-dark lesions. CSF studies were unremarkable. CT chest, abdomen and pelvis showed left upper lobe tree-in-bud nodules, hypoattenuating splenic lesions and a left obturator internus abscess with adjacent osteomyelitis. She underwent CT guided aspiration of the obturator muscle collection, bronchoscopy with Bronchoalveolar Lavage (BAL), biopsy of her skin lesions and ear fluid aspiration. QuantiFERON Gold was positive. Ear fluid was Xpert MTB/RIF assay and acid-fast stain positive. She was started on 4-drug therapy and prednisone. Cultures from the ear fluid, skin tissue, muscle tissue and BAL showed growth of acid-fast bacilli.

TB meningitis is most often due to blood borne spread of the disease from the lungs which may result in miliary nodules in the leptomeninges and brain. The two cases presented illustrate that although TBM is unusual in a developed world, we should suspect it in children of migrants as well as in patients with immunosuppression, where atypical imaging patterns including lack of typical basal enhancement and presence of miliary meningeal nodules may be seen.
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