A 57-year-old man with a history of tuberculosis was admitted to a Korean hospital with a 2-week history of headache, neck pain, and tingling in the right hand. Physical examination revealed decreased grip strength in the right hand. Chest CT scan revealed miliary nodules. Contrast-enhanced MRI of the head revealed a starry sky phenomenon, consisting of numerous small spherical nodules with peripheral signal enhancement in the cerebral hemispheres, basal ganglia, cerebellum, and brainstem, as well as in the upper spinal cord with surrounding edema. No involvement of the meninges was observed. Cerebrospinal fluid analysis was normal and bacteria were not cultured. Sputum culture was positive for Mycobacterium tuberculosis. Doctors In-Suk Bae and Yung Ki Park from Eulji Medical Center in Nowon and Uijeongbu described the case in the New England Journal of Medicine.
Based on the examination results, the patient was diagnosed with central nervous system tuberculomas against the background of miliary pulmonary tuberculosis. Central nervous system tuberculomas are foci of granulomatous inflammation at the sites of mycobacteria penetration through the blood from the primary focus; without treatment, they increase in size over time and undergo caseous necrosis and calcification. They may be accompanied or (as in this case) not accompanied by tuberculous meningitis. The man was prescribed an antimycobacterial therapy regimen and dexamethasone. About a month later, the symptoms of the disease began to decrease; at a control examination after 18 months, they were completely absent, and the MRI of the head was normal. The "starry sky" phenomenon on MRI is most often observed in cysticercosis - brain invasion by larvae of the pork tapeworm that lives in the intestines, but can also occur in tuberculomas, schistosomiasis, Rocky Mountain fever, Japanese encephalitis and some other lesions of the central nervous system. In turn, inflammation of the dura mater can manifest itself on MRI as a sign of the Eiffel Tower at night.