A 20-year-old female presented with a 1-month history of mild intermittent fever and cough with sputum, followed by 15-20 days of progressive bilateral lower limb weakness and inability to walk. She then developed unconsciousness associated with fever, headache, and neck pain. On examination, she had bilateral foot drop, increased lower limb tone and reflexes, and upgoing plantars. Investigations revealed multiple ring enhancing brain lesions involving both cerebral hemispheres in the parasagittal region, suggestive of bilateral tuberculomas. She was diagnosed with bilateral parasagittal tuberculomas and started on anti-tubercular treatment and steroids.

1. Dr. QURBAN HUSSAIN

2.  Anum 20yr/F married house wife resident of Daska
 Presented in M/E with c/o
 On and off mild fever 1 month
 Bilateral lower limb weakness 15-20days
 ASOC 1 day

3. What comes in your mind?
 Differential diagnosis

4. My pt was in her usual state around 1 months back when she
developed mild intermittent fever,usually at night
associated with sweating and mild occasional cough with
yellowish sputum,relieved with medication(pnadol).No
significant other associated symptoms.
Around 20 days back she developed weakness of Rt.leg and
was gradual in onset but progressive and involved Lt.leg
after few days pt become unable to walk or stand.
weakness was not associated with loss of conciouseness
initailly,no tingling sensation or numbness of any
limb,without any loss of bowel or bladder functions.
1 day before presenting to hospital she suddenly become
unconcious.

5.  Unconciousness was associated with
-mild fever,head and neck pain
H/o
-occasional cough e sputum
-Bilateral blurring of vision
-burning micturation
NO h/o
- loss of sensations in lower limbs
-loss of bowel and baldder function
-Fits
-Rashes on the body,Joint pain,alopecia
-Trauma
-Previous similar episode
-Weight loss or anorexia
-Lumps and bumps
-Sleep was normal
- TB contact
- Family H/O similar disease
-Hakeem medications

6. Other system review was normal
Past history;
medical
h/o; 2 miscarriages……first aound 2 months and second
around 5 months of pregnancy
h/o; on and off fever …1-2 months
h/o; treatment for current illness and fever
Surgical;
H/O.. D&C

7. Personal History;
-married for 1 ½ year
-house wife
-non smoker ,non addict,non alchoholic
-normal sleep and appetite
Gynecological History;
-P2A2
-menarche;13 year
-3days/30days…regular…normal
-No h/o dysmennorhea

8. SOCIOECONOMIC STATUS;
Poor
Her husband is labourer
Family history;
No h/o
-Similar disease
-DM,HTN,IHD,CVA,TB,Malignancy,

9. WHAT ELSE YOU WOULD LIKE ASK
IN HISTORY?

10. Differential diagnosis

11. Differential diagnosis
 Spinal cord copression
 Anti-phospholipid antibody syndrome
 MS
 Parasagital meningioma
 Anyother SOL involving parasaggital areas of both
cerebral hemisperes
 SLE
 Sagital sinus thrombosis
 Myeloproliferative disorders/malignancy

12. General physical examinationA young lady of average height and built,well oriented to time, place and person.with vitals,
B.P=100/80
Pulse=86/min,regular
Temp=100 F
R/R=14/min
Pallar +
Jaundie
Cyanosis
Clubbing
Koilonechia
Leuconechia
JVP
Thyroid swelling
Sacro-pedal odema
Inguinal,axillay and cervical lymph nodes
Neck stiffness +

13. CNS Examination;
In emergency her GCS=12/15
Ward GCS=15/15
MOTOR SYSTEM;
Lower limb
Inspection;muscle bulk was equal on both sides
Bilaterally foot drop
Tone; was incresed on both sides and it was spastic.
Reflexs; ankel and knee jerk were exaggeraed on both sides
Plantars; upgoing on both sides
Power; bilaterally around 3/5
Upper limb; normal

14. Bilateral foot drop

15. Sensory system;
All sensations were intact in all 4 limbs
Spine exam;normal with no gibbus or any other deformity
Respiratory system;
unremarkable
Cardiovascular system;
unremarkable
GIT;
unremarkable

16. What else you would like to
examine???

17. Eye examination

18. EYE EXAMINATION
-Visual acuity; rt.6/6
lt.6/18
-Bilateral abduction----absent(6th nerve)
-Bilateral upward and downward gaze limited
-bilateral papill odema
All other cranial nerves were intact.

19. Briefly
 Young female presenting with spastic paraparesis with
no spinal levels,bilateral foot drop and bilteral 6th
nerve palsy

20. Differential diagnosis?

21. Differential diagnosis
 Midline brain lesions
 MS

22. What investigations you would to
do in this case?

23. investigations
 Complete Blood count with ESR
 RFTs and LFTs and S/E,complete urine exam
 X-ray chest
 MRI spine
 CT Brain/MRI Brain with contrast
 Lumber punction for CSF
 Nerve conduction studies of lower limb
 Sputum for AFB
 ANA
 Anti-phospholipid antibodies
 Anti-d DNA antibodies
 HIV
 USG Abdomen pelvis

24. Investigations
HB=9.9
TLC=6600
PLT=550000
B/UREA=22
CREATININE=0.8
BILIRUBIN=0.7
NA+= 144
K+=4.6
HBSAG= neg ANTI HCVE=neg

25. Urine exam and culture;
2-3 pus cells/HPF
Candidial growth
ULTRASOUND Abdomen pelvis;
Normal
X.RAY CHEST AND ECG;
Normal

27. MRI SPINE………normal

28. CSF examination;
Volume; 06ml
Color; colorless
Clot formation; absent
Glucose; 54 mg/dl (BSR at the time of LP 160 mg/dl)
Protein; 338 mg/dl
RBcs; nil/cmm
Tlc; 08/cmm
DLC; polys 50% lymph 50%
Gram staining; no micro organism seen
Z-n staining; no AFB seen

29. ANA facter; negative
Antiphospholipid antibodies ;normal
ESR 60 mm/1st hr
HIV; negative

32.  Multiple ring enhancing lesions involoving both
cerebral hemispheres with perilesional odema in para
falx region with signs of vasculitis.
 Finding are suggestive of bilateral multiple
tuberculomas

33. Diagnosis
 Bilateral parasagital tuberculomas

34. management
Before the definative diagnosis --treatment of
meningoencephalitis was given.
Then after definative diagnosis
-ATT……12-18 months
Isoniazid,rifampicin,pyrazinamide and streptomycin instead of
ethambutol because of better penetraion.
-Steroids……0.15mg/kg i/v or oral for 6-8 weeks then tapper off to
limit neurological deficit and brain odema and inflammation.
-Neurosugical opinion……..conservative management.
-Phsiotherapy of the pt for lower limbs and mobilization

35. Bilateral parasaggital SOL and
Bilateral foot drop
 Foot drop has been known to occur in peripheral
,spinal and muscular dystrophies
 But itcan occur even in central lesions especially when
lesions is involving the parasagital area near motor
strip of leg area.
 Cases has been reported with bilateral foot drops with
paraplegia having bilateral para sagital meningiomas
.

36. Midline lesions of brain
 Parasagital meningioma….more common presents
with paraplegia
 Metastatic SOL
 Tuberculomas
 Sagital sinus thrombosis

37. Parasagital meningiomas
 Incidence rate is 25% of all brain tumors.
 Usually slow growing
 Arise from falx and can extend upward and can
involve superior sagital sinus.
 Presents commonly
-monoparesis of contralateral side initially…can involve
the other side after extension
-signs of raised intracrainal pressure
-fits
-may remain even asymptomatic

38.  Treatment is surgical removal of the lesion.
 Chemotheray and radiotherapy have poor results.
Radiotherapy is mainly used as adjuvant therapy for
incompletely resected, high-grade and/or recurrent
tumors. It can also be used as primary treatment in
some cases of optic nerve meningiomas and some
unresectable tumors.
 Prognosis is excellent with tumors which are
completely resectable.
 Can recur…..incomplete resected,malignant and
multiple tumors.

39. Thank you