A rare association of tuberculous longitudinally extensive transverse myelitis (LETM) with brain tuberculoma

BACKGROUND Longitudinally extensive transverse myelitis is characterized by contiguous inflammatory lesion of spinal cord involving three or more spinal segments. It is a well-recognized but rare presentation of Mycobacterium tuberculosis infection. CASE DESCRIPTION We report a case of young boy diagnosed with multiple brain tuberculomas. He was on antitubercular drugs therapy for 2 months and became asymptomatic. On 2-month followup visit, the patient complained of acute onset progressive sensorimotor, spastic paraparesis with bladder dysfunction. Magnetic resonance imaging of spine showed longitudinally extensive transverse myelitis extending from thoracic spinal segment T2 to T10 level. He was treated with high dose intravenous methylprednisolone therapy and continued on combination of first line four antitubercular drugs. At 6-month followup, patient was able to walk with support. In our patient, clinical features, previous history of brain tuberculoma and spinal neuroimaging confirmed the diagnosis of tuberculous myelitis. The new onset longitudinally extensive transverse myelitis in our patient was may be related to paradoxical response to antitubercular therapy. CONCLUSIONS Our case highlights that tubercular infection might be an important but overlooked cause of longitudinally extensive transverse myelitis. Therefore, clinicians should have a high index of suspicion to diagnose this potentially treatable cause especially in high-risk conditions like tuberculosis endemic areas, associated brain tuberculosis and HIV infection. Our case is unique because of paradoxical presentation of longitudinally extensive transverse myelitis in cranial tuberculomas, already on antitubercular treatment.