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Cerebral tuberculosis post stem cell transplant

A 29-year-old caucasian male presented with headache, confusion and fever, 3 months following an human leucocyte antigen-mismatched allogeneic stem cell transplant for acute myeloid leukaemia. Examination of the cerebrospinal fluid showed an elevated protein level (1.19 g/L) but was otherwise normal. A contrast enhanced T1-weighted magnetic resonance imaging brain scan demonstrated multiple enhancing lesions (panel A). The radiological appearances had a wide differential; the diagnosis of mycobacterium tuberculosis (TB) infection was established following a brain biopsy (panel B: Ziehl-Neelsen stain demonstrating multiple acid fast bacilli, indicated by the arrow). The patient responded well to combination anti-TB treatment although died several months later from an unrelated cause. Tuberculosis is more common in immunocompromised individuals, although it is an uncommon pathogen following stem cell transplant outside areas of endemic infection. Cerebral infection occurs relatively infrequently; the clinical and radiological picture is often non-specific and a brain biopsy may be required to establish the diagnosis.