Starry Sky Intracranial Granulomas with Spinal Granulomas

Tsering Yangchen¹, Ira Shah^2
1Seth G S Medical College, Mumbai, India and Pediatric Infectious Diseases, Levioza Health Care, Mumbai, India, ²

Address for Correspondence: Tsering Yangchen, Seth G S Medical College, Mumbai, India. Email: mbbs160172@kem.edu

Clinical Problem:
An 8 years old female, presented in Feb 2015 with fever and headache for 15 days. She was admitted in a hospital a week ago after she developed right lateral rectus palsy. There was no contact with a patient having TB. CT brain showed nodular area with surrounding hypodensity in left anterior gangliocapsular region. MRI brain showed granulomas in cerebral, cerebellar hemispheres and brain stem along with moderate obstructive hydrocephalus with meningeal enhancement like a starry sky appearance (Figure 1). The lesions were hyperintense on T1 and hypointense on T2 and Flair. There were also spinal granulomas. (Figure 2) X-Ray chest was normal, Mantoux test was negative and Dengue IgM positive. Cerebrospinal fluid (CSF) was cloudy with 800 cells (95% polymorphs and 5% lymphocytes), proteins 42 mg/dl glucose 27mg/dl with corresponding blood sugar of 135mg/dl. CSF geneXpert was negative for Mycobacterium tuberculosis (MTB). HIV Elisa was negative. On examination, weight was 16.5 kg, she had meningeal signs and right lateral rectus palsy.

What is the likely diagnosis?