Hypertrophic cranial pachymeningitis coinfection with tuberculosis and actinomycosis
A 35-year-old male presented with progressive headache, paraesthesia, and blurred vision. The MRI showed diffuse meningeal enhancement with thickening, along with areas of brain edema [Figure 1a-c]. Despite this mild meningeal inflammatory syndrome, cultures were negative. Although there was an initial perceived response to steroids, the patient had a relapse. A dural biopsy revealed epithelioid-giant cell granulomas with caseous necrosis, and TB- PCR of tissue was positive [Figure 1d]. In addition, the anaerobic culture (requiring about 4 weeks) eventually grew Actinomyces species. The patient had a good response to oral ciprofloxacin and antituberculous medication. The conclusion was that dural biopsy, histology, and cultures are imperative in pachymeningitis for establishing the diagnosis and guiding treatment.