Acute paraparesis with tuberculous meningitis.

Accepted 25 November 1997 A 30-year-old-man who had low-grade intermittent fever and occasional vomiting of 2 months duration, presented with acute onset of complete weakness of both lower limbs and urinary retention. There was no family history or past history of tuberculosis. Examination revealed right 6th nerve palsy, marked neck rigidity and positive Kernig's sign. The patient had paraparesis with power 0/5 on the MRC scale. His bladder was distended and was palpable in the suprapubic region. Deep tendon reflexes were brisk in the lower limbs. Both plantars were extensor, and abdominal and cremastric reflexes were not elicitable. He had loss of all forms of sensations below the umbilicus; power in the upper limbs was normal. All haematological, serum biochemical and urine parameters were normal. Cerebrospinal fluid (CSF) examination revealed protein 0.14 g/l, cells 336 x 106/1 (all mononucleocytes), sugar 1.3 mmol/l. Enzyme-linked immunosorbent assay (ELISA) for antituberculous antibodies was strongly positive. Cranial computed tomography (CT) revealed hydrocephalus, exudates in basal cisterns and marked gyral enhancement. Radiographs of thoracic spines, chest and a lumbar myelogram were normal. Contrast-enhanced magnetic resonance imaging (MRI) of spine revealed an intensity-enhancing disc lesion at the thoracic 8-9 level of the spinal cord (figure).