Bono Keiko, Sengoku Renpei, Matsuno Hiromasa, Morita Masayo, Matsushima Satoshi, Iguchi Yasuyuki
Department of Neurology, The Jikei University School of Medicine.
Rinsho Shinkeigaku. 2014;54(2):140-5. doi: 10.5692/clinicalneurol.54.140.
A 76-year-old woman was admitted to our hospital because of convulsions that developed after a 1-month history of progressive right-leg palsy. MRI showed thickening of the meninges with gadolinium enhancement in the left parietal lobe and it revealed pia-subarachnoid space pattern. A lumbar puncture was performed, and cerebrospinal fluid analysis revealed no abnormality. Her serum adenosine deaminase level was elevated (28.7 IU/l). The results of serum cultures were normal. To differentially diagnose collagen disease, infection, malignancy, and inflammation of uncommon causes, we conducted brain and meningeal biopsies on the 15th hospital day. Histopathological examination of the brain tissue showed mainly necrosis and inflammation. There was severe pachymeningeal thickening without necrosis. Although it was difficult to reach a definitive diagnosis, a tissue sample taken from under the leptomeninges tested positive for mycobacterium on Ziehl-Neelsen staining. The results of polymerase chain reaction for mycobacterium were negative in the meningeal tissue. The patient received anti-tuberculous drugs, anti-nontuberculous mycobacteriosis drugs, and corticosteroids to treat Mycobacterium tuberculosis and nontuberculous mycobacterium. After starting treatment, the findings on magnetic resonance imaging improved dramatically, and no convulsions occurred during hospitalization. She was discharged on the 153rd hospital day without any neurological deficit. Because previous studies have reported that isolated mycobacterium meningitis is a diagnostically challenging condition, brain and meningeal biopsies should be considered in patients with gadolinium enhancement in the meninges.
一名76岁女性因右腿进行性麻痹1个月后出现惊厥而入住我院。磁共振成像（MRI）显示左侧顶叶脑膜增厚并伴有钆增强，呈现软脑膜 - 蛛网膜下腔模式。进行了腰椎穿刺，脑脊液分析未发现异常。她的血清腺苷脱氨酶水平升高（28.7 IU/l）。血清培养结果正常。为了鉴别诊断胶原病、感染、恶性肿瘤以及罕见原因引起的炎症，我们在住院第15天进行了脑和脑膜活检。脑组织的组织病理学检查主要显示坏死和炎症。硬脑膜有严重增厚但无坏死。尽管难以做出明确诊断，但取自软脑膜下的组织样本经齐-尼氏染色显示结核杆菌阳性。脑膜组织中结核杆菌的聚合酶链反应结果为阴性。患者接受了抗结核药物、抗非结核分枝杆菌病药物和皮质类固醇治疗结核分枝杆菌和非结核分枝杆菌。开始治疗后，磁共振成像结果显著改善，住院期间未再发生惊厥。她于住院第153天出院，无任何神经功能缺损。由于先前的研究报告称孤立性结核性脑膜炎是一种诊断具有挑战性的疾病，对于脑膜有钆增强的患者应考虑进行脑和脑膜活检。
