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Contrast-enhanced CT scan at the level of the basal cisterns, showing bilateral subtle enhancement along the posterior end of the gyrus rectus due to basal collaterals in association with moyamoya. There was no abnormal dural enhancement noted in the rest of the dural covering
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Figure 2: Contrast-enhanced CT scan at the level of the basal cisterns, showing bilateral subtle enhancement along the posterior end of the gyrus rectus due to basal collaterals in association with moyamoya. There was no abnormal dural enhancement noted in the rest of the dural covering

Mentions: ECG and blood chemistry (including blood sugar), complete blood count (CBC) and liver profile were normal. Lumber puncture was carried out to rule out tuberculous meningitis. Cerebrospinal fluid (CSF) was clear with an opening pressure of 40 mm H2O, and analysis of CSF revealed the following values: WBC count of 5 cells/mm3(100% lymphocytes); glucose level 3.8 mmol/L; and protein level 0.78 g/L. Gram and Zeihl-Neelsen stains were negative. Echocardiography and holter monitoring also were normal, whereas urgent brain computed tomography (CT) showed multiple infarctions without abnormal dural enhancement [Figures 1 and 2]. Screening for thrombophilia and vasculitis was carried out. Anti-thrombin III, activated protein C resistance, factor V Leiden, protein C, protein S, clotting time, prothrombin time, activated partial thromboplastin time, fibrinogen, anticardiolipin antibody, lupus anticoagulant screen, homocystine, antinuclear antibody (ANA), C3, C4, C-reactive protein (CRP) and anti-neutrophil cytoplasmic antibodies (ANCAs), all these tests were within normal limits. The electroencephalogram (EEG) showed epileptic discharges. Magnetic resonance imaging (MRI) showed infarction at the head of the left caudate nucleus, the antero-lateral aspect of putamen and intervening internal capsule [Figure 3], whereas magnetic resonance (MR) angiography showed a picture consistent with moyamoya. Brain CT angiography was performed and it showed the same pictures [Figure 4].

Moyamoya syndrome in a known case of pulmonary tuberculosis

Khan FY, Kamal H, Musa R, Hayati A - J Neurosci Rural Pract (2010)

Bottom Line: Brain CT angiography was performed and it showed the same pictures.On the following days, she was discharged on antituberculous medications, antiepileptic and oral hypoglycemic treatment.After 1 year, the patient was seen in the clinic, she was well and seizure-free.

Affiliation: Department of Medicine, Hamad Medical Corporation, Hamad General Hospital, PO Box 3050, Doha, Qatar.

ABSTRACT
We report an unusual association of pulmonary tuberculosis with moyamoya syndrome in a 30-year-old Filipino female who was admitted to our hospital with a 1-week history of fever and cough. Chest X-ray showed widespread bilateral consolidation with cavity, whereas sputum was positive for acid fast bacilli (AFB). Two weeks after starting antituberculous treatment, the patient developed two episodes of loss of consciousness, which were unwitnessed. Urgent brain computed tomography (CT) showed multiple infarctions, suggesting vasculitis. The electroencephalogram showed epileptic discharges. Magnetic resonance angiography showed a picture consistent with moyamoya disease. Brain CT angiography was performed and it showed the same pictures. The patient was diagnosed with pulmonary tuberculosis-associated moyamoya syndrome. On the following days, she was discharged on antituberculous medications, antiepileptic and oral hypoglycemic treatment. After 1 year, the patient was seen in the clinic, she was well and seizure-free.

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