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| CASE REPORT |
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| Year : 2015 | Volume
: 4
| Issue : 1 | Page : 76-78 |
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Tubercular chronic adhesive arachnoiditis in a patient with diastematomyelia
Shruti Chandak1, Arjit Agrawal1, Ashutosh Kumar2
1 Department of Radiodiagnosis and Imaging, Teerthanker Mahaveer Medical College and Research Centre, Moradabad, Uttar Pradesh, India
2 Department of Pathology, Teerthanker Mahaveer Medical College and Research Centre, Moradabad, Uttar Pradesh, India
| Date of Web Publication | 13-Feb-2015 |
Correspondence Address:
Shruti Chandak
Department of Radiodiagnosis and Imaging, Teerthanker Mahaveer Medical College and Research Centre, Delhi Road, Moradabad - 244 001, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2278-0521.151414
Chronic adhesive arachnoiditis is the third and final stage of tubercular radiculomyelitis. Its coexistence in a patient of diastematomyelia which is a congenital anomaly of splitting of spinal cord has not been reported previously. We present a very rare case of chronic adhesive arachnoiditis and diastematomyelia in a teenage girl presenting with bilateral lower limb weakness where magnetic resonance imaging (MRI) has been crucial to the diagnosis. Keywords: Bilateral lower limb weakness, chronic adhesive arachnoiditis, diastematomyelia, MRI, tubercular radiculomyelitis
How to cite this article:
Chandak S, Agrawal A, Kumar A. Tubercular chronic adhesive arachnoiditis in a patient with diastematomyelia. Saudi J Health Sci 2015;4:76-8 |
| Introduction | |  |
Spinal tuberculous arachnoiditis is a rare complication of central nervous system (CNS) tuberculosis that can result in severe peripheral neurological deficit. [1] Diastematomyelia is a rare congenital spinal cord abnormality characterized by longitudinal "splitting up" of the spinal cord into two. [2] We present a unique case of chronic adhesive arachnoiditis of tubercular etiology in a patient of diastematomyelia. To the best of our knowledge, this is the first such reported case in literature.
| Case report | | |
A 27-year-old female patient presented to us with history of progressive weakness in both the lower limbs over 6 months. The patient had a history of being treated for tubercular meningitis about 4 years back. The tubercular meningitis had then been diagnosed by magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) studies. The patient had no bowel/bladder incontinence. The patient also did not have any cutaneous stigmata of spina bifida. An MRI of thoracolumbar spine was asked for which showed expansion of entire spinal cord with multiple cysts and syrinx formation [Figure 1]. Conglomeration and thickening of nerve roots was noted from L1 to L5 level with peripheral clumping and empty thecal sac at L1-L2 level suggestive of type 2 arachnoiditis [Figure 2]. Uniform clumping in the centre and periphery suggestive of type 1 arachnoiditis was seen below L2 level [Figure 3]. Splitting of spinal cord into two hemicords within a single dural sac was seen in the cervicodorsal and lumbar regions without any dividing septa suggestive of type 2 diastemetomyelia [Figure 4]. Post contrast enhancement was seen involving dura of upper cervical spine in anterior aspect [Figure 5] and along nerve sheaths of bilateral C2 nerve roots [Figure 6]. Due to the presence of antecedent tubercular meningitis, a diagnosis of spinal tuberculous arachnoditis with diastematomyelia was made and the patient was started on antitubercular therapy. | Figure 1: T2W sagittal image showing expansion of entire spinal cord with multiple cysts and syrinx formation
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 | Figure 2: T2W axial image showing peripheral clumping and empty thecal sac at L1-L2 level suggestive of type 2 arachnoiditis
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 | Figure 3: T2W axial image showing uniform clumping in the centre and periphery suggestive of type 1 arachnoiditis
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 | Figure 4: T2W axial image showing splitting of spinal cord into two hemicords within a single dural sac without any dividing septa suggestive of type 2 diastemetomyelia
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 | Figure 5: Post-contrast T1W sagittal image showing dural enhancement of upper cervical spine in anterior aspect
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 | Figure 6: Post-contrast T1W coronal image showing enhancement along nerve sheaths of bilateral C2 nerve roots
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| Discussion | | |
Tuberculosis is a rare cause of spinal arachnoiditis. It may occur primarily or secondary to intracranial or vertebral infection. [3] Intradural tuberculosis has been variously termed as intradural extramedullary tuberculosis, spinal arachnoiditis and chronic adhesive arachnoiditis and all these are designated as tuberculous radiculomyelopathy which could occur due to primary meningitis or downward extension from intracranial tubercular meningitis or secondary spread from adjacent vertebral disease. Among these, downward spread from intracranial tubercular meningitis is most common. The thoracic cord is more frequently involved, followed by lumbar and cervical cords. [4] There are three stages of tubercular radiculomyelitis namely radiculitis, arachnoiditis and adhesive arachnoiditis. [5]
Our case was in the third stage of tubercular radiculomyelitis and the infection originated from a previous tubercular meningitis.
Classically, there are three MR patterns of arachnoiditis: [6]
Type 1: Central type-roots are clumped to the centre of thecal sac
Type 2: Peripheral type-roots are adherent to the margins of the dural sac
Type 3: Adherent roots to one side of thecal sac resembling a soft tissue mass.
Our case showed features of both type 1 and type 2.
Diastematomyelia is a rare form of spinal dysraphism characterized by a sagittal cleft of varying extent in the spinal cord, conus medullaris or filum terminale due to an osseous, cartilaginous or fibrous septum producing a complete or incomplete sagittal division of the spinal cord into two hemicords. [7]
Diastematomyelia usually occurs between D9 and S1 levels and cervical diastematomyelia is very rare. In about half of the patients, the hemi-cords are contained in a single dural sac (type 2), while in the remaining, they lie within separate dural sacs (type 1). In the latter, bony or fibrous spurs are usually found between the two sacs. Diastematomyelia may be associated with intradural tumours, tethered cord, inclusion dermoid, lipoma, syringohydromyelia, Chiari malformation More Details, myelodysplasia or spinal dysraphism. [2] Our patient had type 2 diastematomyelia.
Chronic adhesive arachnoiditis presents a complex clinical picture making the clinical diagnosis difficult. [8] Diastematomyelia is uncommon and rarely presents in adulthood. Progressive weakness without any previous neurologic deficit or neurocutaneous stigmas of an underlying spinal cord abnormality may develop in the adult with unrecognized diastemotomyelia. [9] Hence, MRI is absolutely crucial for the diagnosis of the above conditions. The simultaneous presence of above two conditions is exceedingly rare and has not been previously described in literature to the best of our knowledge.
| References | | |
| 1. | Poon TL, Ho WS, Pang KY, Wong CK. Tuberculous meningitis with spinal tuberculous arachnoiditis. Hong Kong Med J 2003;9:59-61.  |
| 2. | Kachewar SG, Sankaye SB. Diastematomyelia - A report of two cases. J Clin Diagn Res 2014;8:RE01-2. |
| 3. | Chang KH, Han MH, Choi YW, Kim IO, Han MC, Kim CW. Tuberculous arachnoiditis of the spine: Findings on myelography, CT, and MR imaging. AJNR Am J Neuroradiol 1989;10:1255-62. |
| 4. | Konar SK, Rao KN, Mahadevan A, Devi BI. Tuberculous lumbar arachnoiditis mimicking conus cauda tumor: A case report and review of literature. J Neurosci Rural Pract 2011;2:93-6. [ PUBMED]  |
| 5. | Burton CV. Lumbosacral arachnoiditis. Spine 1978;3:24-30. [ PUBMED] |
| 6. | Ross J, Masaryk T, Modic M, Delamater R, Bohlman H, Wilbur G, et al. MR imaging of lumbar arachnoiditis. AJR Am J Roentgenol 1987;149:1025-32. |
| 7. | Singh H, Maurya V, Saini M. Diastematomyelia. Indian J Radiol Imaging 2000;10:255-7. |
| 8. | Rice I, Wee MY, Thomson K. Obstetric epidurals and chronic adhesive arachnoiditis. Br J Anaesth 2004;92:109-20. |
| 9. | Lewandrowski KU, Rachlin JR, Glazer PA. Diastematomyelia presenting as progressive weakness in an adult after spinal fusion for adolescent idiopathic scoliosis. Spine J 2004;4:116-9. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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