IMAGES IN NEUROLOGY
|Year : 2021 | Volume
| Issue : 6 | Page : 927-928
Preferential corticospinal tract involvement in a case of neuromelioidosis
Sundar Shanmugam1, Rithvik Ramesh1, Raj Kumar2, Prabhu Radhan3, Bodapati Pawan Kumar2
1 Department of Neurology, Sri Ramachandra Institute of Higher Education and Research, Ramachandra Nagar, Porur, Chennai, Tamil Nadu, India
2 Department of Internal Medicine, Sri Ramachandra Institute of Higher Education and Research, Ramachandra Nagar, Porur, Chennai, Tamil Nadu, India
3 Department of Radiology, Sri Ramachandra Institute of Higher Education and Research, Ramachandra Nagar, Porur, Chennai, Tamil Nadu, India
|Date of Submission||25-Nov-2020|
|Date of Decision||29-Dec-2020|
|Date of Acceptance||18-Jun-2021|
|Date of Web Publication||17-Dec-2021|
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Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shanmugam S, Ramesh R, Kumar R, Radhan P, Kumar BP. Preferential corticospinal tract involvement in a case of neuromelioidosis. Ann Indian Acad Neurol 2021;24:927-8
|How to cite this URL:|
Shanmugam S, Ramesh R, Kumar R, Radhan P, Kumar BP. Preferential corticospinal tract involvement in a case of neuromelioidosis. Ann Indian Acad Neurol [serial online] 2021 [cited 2022 Jan 18];24:927-8. Available from: https://www.annalsofian.org/text.asp?2021/24/6/927/332554
| Case Vignette|| |
A 32-year female with no prior comorbidities presented with complaints of fever and radiating low-back pain for the past one week. These symptoms were subsequently associated with paraparesis and altered sensorium for the last two days. Examination revealed a febrile woman with neck-stiffness, lower-limb power 1/5, absent reflexes, and mute plantars. With blood routines revealing an elevated WBC count and chest X-ray being normal, contrast-enhanced MRI lumbosacral spine was done, which showed features suggestive of arachnoiditis at the L1-L2 level [Shown in [Figure 1]] with MRI brain revealing mild hydrocephalus. Subsequent CSF analysis revealed 305 cells (P-60%, L- 40%) with proteins at 1014.5 mg/dl and sugars at 24 mg/dl with CSF TB PCR showing negative results. Contrast-enhanced MRI brain was repeated the next day, which showed mild hydrocephalus with diffusion restriction, specifically involving bilateral corticospinal tracts [Shown in [Figure 2]]. She was empirically initiated on antituberculous drugs and steroids. CSF culture showed Gram-negative bacilli and meropenem was added to the regimen. Despite treatment, the patient continued to deteriorate and eventually passed away. Post demise, the CSF culture-confirmed Burkholderia pseudomallei as the causative agent.
|Figure 1: Arachnoiditis. (a) MRI lumbosacral spine axial cut, T2 weighted image, showing two CSF loculations measuring 3.8 × 0.7 × 0.9 cm (cc × ap × trans on the left side) and 1.5 × 0.3 × 0.3 cm (cc × ap × trans on the right side) noted at the L1-L2 vertebral level and (b) showing clumping of roots surrounding the CSF pockets (red arrows)|
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|Figure 2: Corticospinal tract involvement. (a, b) MRI brain axial image, diffusion-weighted sequence (a) showing diffusion restriction involving bilateral corticospinal tracts (right more than left) at the level of corona radiata, with (b) showing the corresponding apparent diffusion coefficient image. (c, d) MRI brain axial image, diffusion weighted image sequence (c) showing diffusion restriction involving bilateral corticospinal tracts at the level of basal ganglia, with (d) showing the corresponding apparent diffusion coefficient image. (e) Reconstructed DWI coronal images showing diffusion restriction involving preferentially the corticospinal tracts along its course, right more than left|
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This case illustrates the affinity of Burkholderia to white matter tracts, specifically to corticospinal tract by the formation of multiple microabscesses as described previously in the literature and these have diffusion restriction. Other areas commonly involved include brainstem and cranial nerves, especially trigeminal nerve. This case highlights the consideration of melioidosis as one of the clinical differentials of meningoencephalitis in endemic regions, especially when encountering diffusion restriction limited to corticospinal tracts and initiating early appropriate treatment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Hsu CC, Singh D, Kwan G, Deuble M, Aquilina C, Korah I, et al
. Neuromelioidosis: Craniospinal MRI findings in burkholderia pseudomallei infection. J Neuroimaging 2016;26:75-82.
Currie BJ, Fisher DA, Howard DM, Burrow JN. Neurologicalmelioidosis. Acta Tropica 2000;74:145-51.
[Figure 1], [Figure 2]