Abstract

This is a rare case report about hypertrophic cranial pachymeningitis coinfection with tuberculosis and actinomycosis in a 35-year-old male. The patient presented with progressive headache, paraesthesia, and blurred vision. Dural biopsy, histology, and cultures are imperative in pachymeningitis for establishing the diagnosis and guiding treatment.

Keywords: Actinomycosis, Hypertrophic cranial pachymeningitis, Intracranial infection, Pachymeningitis, Tuberculosis

IMAGE REPORT

A 35-year-old male presented with progressive headache, paraesthesia, and blurred vision. The MRI showed diffuse meningeal enhancement with thickening, along with areas of brain edema [ Figure 1a - c ]. Despite this mild meningeal inflammatory syndrome, cultures were negative. Although there was an initial perceived response to steroids, the patient had a relapse. A dural biopsy revealed epithelioid-giant cell granulomas with caseous necrosis, and TB- PCR of tissue was positive [ Figure 1d ]. In addition, the anaerobic culture (requiring about 4 weeks) eventually grew Actinomyces species. The patient had a good response to oral ciprofloxacin and antituberculous medication. The conclusion was that dural biopsy, histology, and cultures are imperative in pachymeningitis for establishing the diagnosis and guiding treatment.

Figure 1:

Axial (a), sagittal (b), and coronal (c) cranial magnetic resonance imaging following gadolinium injection showing diffuse meningeal enhancement and thickening, along with areas of brain edema. Dural biopsy revealing epithelioid-giant cell granulomas with caseous necrosis (hematoxylin-eosin staining) (d).

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Conflicts of interest

There are no conflicts of interest.