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Diffuse multiple cystic lesions in the brain

Figure 1. MRI Brain (T2 weighted) transverse section showing diffuse multiple cystic lesions intra-axial and extra axial involving bilateral cerebral hemispheres and basal ganglia and meninges (white arrow) Figure 2. MRI Brain sagittal (T1) and coronal sections (T2) showing diffuse multiple cystic lesions involving cerebellum, tongue (white solid arrow), extra-ocular muscles and neck muscles (white dotted arrow)

Anjali Bharani
A 10-year-old female child presented with fever, irritability, altered sensorium for 20 days and inability to speak for 15 days. There was no contact with a patient suffering from tuberculosis (TB). On examination, she was febrile, disoriented, had hypertonia with brisk deep tendon reflexes along with left sided upper motor neuron type facial palsy and meningeal irritation. Other systems were normal. Investigations revealed normal cerebrospinal fluid (CSF) analysis, normal X-ray chest, normal stool examination and negative Mantoux test. HIV serology also was negative. MRI brain showed multiple intra-axial, extra-axial, extra-cranial hyperintense cystic lesions with intralesional hypointense foci (cyst with dot), involving bilateral cerebral hemispheres (capsule-ganglionic region), thalamus (Figure 1) and brainstem, bilateral cerebellar hemispheres, bilateral muscles of mastication, bilateral extraocular muscles, tongue, neck muscles, upper limb muscles (Figure 2). Multiple foci of calcification were also noted. Peripheral enhancement was seen on post contrast scan. Ophthalmic evaluation did not show any intra-ocular involvement.
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