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.
The authors certify that they have obtained all appropriate patient consent.