Case Report Section A case of tuberculous spinal HISTORY AND EXAMINATION PCR was negative.He was treated with 12 months of anti- A 31-year-old Iraqi man, who had been in the UK since tuberculous chemotherapy and baclofen for radicular 2002, presented with loin pain then a three-month histo- pain. His neurological symptoms and signs improved ry of progressive leg weakness and sensory disturbance, post . urinary hesitancy and urgency, and erectile failure. He had smear positive pulmonary tuberculosis one year pre- DISCUSSION viously and had been treated with 6 months of anti- Secondary intradural spinal arachnoid formation can tuberculous chemotherapy. be caused by trauma (including surgery and lumbar Dr Wendy Phillips is Tone in the legs was increased bilaterally. He had pyrami- puncture), arachnoiditis and . Secondary a Specialist Registrar dal weakness of the legs (3-4/5 on left, 4/5 on the right) in Neurology in spinal arachnoiditis can result from inflammatory or Cambridge. She is with brisk reflexes and ankle clonus and an extensor plan- chemical (e.g. contrast agents, anaesthetics), currently researching tar on the left. He had impaired proprioception on the left subarachnoid haemorrhage, or trauma. Spinal arach- molecular echanisms leg below the hip and reduced vibration sense below the noiditis results from inflammation of the theca, causing underlying Huntington's disease knees bilaterally. clumping and deformation of the nerve roots, and a polyradiculopathy. The may be involved sec- INVESTIGATIONS ondary to an infective myelopathy or secondary to Routine blood tests showed a mildly raised ESR. HIV ischaemic myelopathy due to inflammation of the vascu- serology was negative. CXR initially showed parenchymal lature, cord atrophy, and intramedullary . Intradural nodules in the right upper and mid zone and on the left cysts can displace and deform the cord. MRI is the inves- lower zone but at follow up the CXR was normal. tigation of choice and may show deformation of nerve CSF was acellular and microscopy for AAFB was negative. roots, nodules in the subarachnoid space, loculations and Protein was 0.2 and glucose 3.8 (plasma 4.5). meningeal enhancement, although the severity of MRI MRI (see figure 1) showed multiloculated intradural CSF appearance does not correlate well with symptoms. collections displacing the spinal cord anteriorly over T2- Surgical management is often unsuccessful. T8. References DIAGNOSIS Bradley WG, Daroff RB, Fenichel GM, Marsden CD. Tuberculous spinal arachnoiditis. Neurology in Clinical Practice, 3rd Edition, 2000; Butterworth and Heinemann. MANAGEMENT Lolge S, Chawla A, Shah J, Patkar D, Seth M. MRI of spinal A T3-T9 laminectomy and debridement with exploration intradural arachnoid cyst formation following tubercu- of intradural arachnoid cysts was performed and he was lous meningitis. The British Journal of Radiology, 2004; given 8mg dexamethosone perioperatively. A chronic 77: 681-684 pachymeningitis was diagnosed on histology but there Orendacova J et al. Cauda equina syndrome. Progress in were no granulomas, and microscopy for AAFB and TB neurobiology, 2001; 64 (6): 613-637.

Figure 1: MRI showed multi- loculated intradural CSF collections displacing the spinal cord anteriorly over T2-T8.

Correspondence to our Case Report Coordinator: Alastair Wilkins, Addenbrooke’s Hospital, Cambridge. E-Mail. [email protected]

ACNR WEB CONTENT - PREPARED NOVEMBER 2004