Fig. 1.

Sagittal and axial contrast-enhanced MRI images of a 31-year-old woman with TBM, before (A & B) and at the time of (C & D) a severe paradoxical reaction. Baseline sagittal (A) and axial (B) images show no neuroinflammatory features of TBM. Repeat imaging after 2 months shows extensive tuberculous exudate filling the cisterna pontis (anterior to the pons), interpeduncular cistern (anterior and superior to the pons), and cisterna ambiens (superior to the cerebellum), of the brain (C & D). Sagittal imaging (C) shows clear delineation between exudate-filled cistern and surrounding brain structures. Axial imaging (D) demonstrates a thick exudative ring with anterior projections, typical of basal exudate appearances in TBM.

MRI = Magnetic resonance imaging. TBM = Tuberculous meningitis.