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All right, we will look at the case. Third case now, give me one second.

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So this patient came with

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headaches and altered mental status.

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This is a very young patient, young adult,

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I would say 18 year old who came with symptoms of headache and

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irritability and altered mental status.

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The most interesting sequence here is flare sequence where you can see

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multiple areas of hyperintensities On diffusion weight

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images, you see multiple areas,

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tiny foci of diffusion restriction scattered in both the cerebral hemispheres

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everywhere in corpus colorism in the white matter,

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in the sub particle white matter.

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And these are real as are seen on the a d C

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maps,

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you can see multiple areas of hypo intensity on ABC maps consistent with

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uh, real lesions. Now there is some t2, uh, shine through,

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however majority of the lesions are restricting on poles,

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contrast images,

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you can see innumerable enhancing lesions in both the

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cerebral hemispheres and there is central high pointin signal which is

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consistent with non enhancing area.

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So we are dealing with a patient who came with headache and

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altered mental status with innumerable enhancing lesions,

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both in the supra tentorial hemisphere and infra tentorial hemisphere.

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You can see both the cerebral hemis cerebellar hemisphere,

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so have also multiple enhancing lesions.

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The CT was done. Uh, we will,

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they will see the differential soon. However,

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I would like to show you CT images first before we decide on what exactly

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this is. As soon as those images were seen,

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there was a suspicion of this could be metastasis.

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But in addition to that,

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there are other differentials which we are going to discuss soon. Uh,

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CT was obtained to see what exactly is going on in the chest so that we can

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narrow over differential on CT of the chest.

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You see there are multiple innumerable mery nodules

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throughout the lungs. Both the lungs have ex multiple,

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multiple diffusely spread extensive mallary nodules.

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On top of that,

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there is some plural effusion, which looks like it's partially lod.

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It has some adhesions and also there are some lymph nodes.

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These are not enlarged by the criteria of, uh, caus calling them,

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uh, pathologically enlarged or pathologically enlarged lympho. However,

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uh, we saw multiple mallary nodules with some kind of suggestion.

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Ofd effusion on the left side.

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The patient while getting the CT scan also said that my back hurts.

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So she was then transported to M mri and you can see

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there is a heterogeneous signal in the right. So as muscle

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on T image,

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you can see there is some hyperintensity along the anterior longitudinal

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ligament and some altered signal intensity of the vertical body.

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Here on post contrast image,

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you see there is some kind of enhancing tissue anterior to these vertical

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bodies. In addition to that,

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there is some fluid collection along the posterior aspect of the vertebral

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bodies. There is erosion of the superior nplate as well as there is a,

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a non enhancing area in the vertebral body.

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So L one,

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L two discitis osteomyelitis is suggested on these images.

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We also did diffusion with images to confirm the same findings.

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Now, when we were looking at these on T2 weight images,

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there was some suggestion of some bright spots in the liver.

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So then the patient also got MRI of the liver to confirm

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whether there is any abnormality in the liver. And guess what was there?

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We saw this partially lod effusion on our prior ct.

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Not that impressive finding on T1 post contrast image.

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However,

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on diffusion with images, again,

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you see multiple tiny areas of diffusion restriction throughout the liver

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and maybe in the kidneys. So let's share the question please.

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So we have to choose in between meds.

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Disseminated TB viral infection like covid,

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covid can be in a differential

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and vasculitis disseminated tb. Excellent. All right,

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so

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disseminated TB is a life-threatening disease and is spread by

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hematogenous route. Uh,

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the bacteria involved is mycobacterium tuberculosis.

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Now the good news is disseminated TB is seen only in one to 2% of the

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immunocompetent patients. The classic,

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classic description and radiology teaching is the mallary pattern,

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Mallary pattern of nodules or nodular distribution throughout the long-term

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camera, uh, on both sides, on chest radiography or on ct.

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However, if you are highly suspecting, um,

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disseminated TB and the millary tbu mallary nodules are not present,

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then that is called a cryptic tb.

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Do not hesitate to call disseminated TB if the other features are pointing

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towards disseminated tb. Uh,

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important findings are when there are presence of two or more

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non-contiguous sites of infection, then we, we suspect disseminated tb.

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Disseminated.

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TB happens because of reactivation or it happens because of the

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progressive primary infection.

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Progressive primary infection is seen in relatively younger age group less than

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five years of age.

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In the brain you can see tuber bras, abscesses,

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abscesses or larger abscesses meningitis and celebrate meningitis

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In these patients who have disseminated TB will be predominantly basilar in

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distribution. If you see lymph pathy,

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it's usually maced because it causes a lot of gra matter for, uh,

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gran formation in the lymph nodes and it causes a lot of fibrosis and, uh,

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reactive inflammation. So usually they're matted lymph nodes.

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All the lymph nodes will be very close to each other and and will be seen as

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adherent lymph pathy. Um,

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matted lymph nodes are commonly seen in the belly,

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so intraabdominal retinopathy, um, uh,

7:31

in thein you can also see a c, which could be lod.

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There could be just patone thickening or the patient can present with hepato,

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which is a very non-specific finding. Now the pots spine,

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as we saw in our patient, um,

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happens because of the sub ligamentus spread of the infection.

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That's why you saw along the anterior long al ligament there was hyperintensity.

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On tve image, it typically spares the posterior elements.

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Uh, it can result into Gibbs formation.

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Gibbs formation is focal kyphosis at the level of infection. Uh,

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it can also result in vertebra plan. So for, uh, any test takers,

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if this is a very good thing to remember as a differential vertebra plan can be

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seen in L C H in patients who have leukemia lymphoma and in patients who have

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disseminated tb.

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So as abscesses are anomic for tb,

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you can definitely have SOS accesses from other bacterial sources. However,

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if you look at the SOS and if it enhances,

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shows diffusion restriction and has multid collection,

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think about TB as your differential, as your top differential.

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So this was a case of disseminated tb. Um,

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she got better after the treatment and diagnosis and doing well.