来源：双语学影像；本期病例选自AuntMinnie.com
Our appreciation is extended to Dr. Bonny Lee, Eastern Virginia Medical School in Norfolk, VA; Nora Haney, Tulane University School of Medicine in New Orleans; Dr. Lynn Bergren, Hampton Veterans Affairs Medical Center in Hampton, VA; and Dr. José Morey, University of Virginia in Charlottesville, VA, for contributing this case.
History and MR images
A 54-year-old man with a history of sarcoidosis, hypertension, and diabetes mellitus who presents with pain in thoracic region, fever, and vomiting.
54岁男性，有肉样瘤病、高血压、糖尿病病史。近期出现胸痛、发热、呕吐。
MR images are shown below.
1.What is the imaging finding?
Smooth diffuse leptomeningeal enhancement
软脊膜弥漫性增厚
Diffuse enhancement along spinal cord
脊髓弥漫性强化
Thickened iso- to hypointense dura
硬脊膜增厚、呈等至低信号
Fusiform cord enlargement
脊髓增粗呈梭形
2.The differential diagnosis includes meningitis, leptomeningeal metastasis, lumbar arachnoiditis, and Guillain-Barré syndrome. What is the most likely diagnosis?
鉴别诊断包括脊膜炎、软脊膜转移瘤、腰椎蛛网膜炎、格林巴利综合征。最有可能的诊断是什么？
Guillane-Barré syndrome
Leptomeningeal carcinomatosis
Neurosarcoidosis
Spinal meningitis
Additional questions
3.Imaging is often negative in early spinal meningitis.
早期的脊膜炎影像学常呈阴性。
True
False
4.IV gadolinium increases sensitivity in detecting meningitis.
钆对比剂增强扫描可以增加本病检查的敏感性。
True
False
5.What is the most common complication（并发症） of meningitis?
Transient hydrocephalus 暂时性脑积水
Cranial nerve involvement 颅神经受累
Thrombosis/infarction 栓塞形成/梗塞
Abscess formation 脓肿形成
答案：
Smooth diffuse leptomeningeal enhancement
Smooth diffuse leptomeningeal enhancement is seen in these MR postcontrast images.
Spinal meningitis
Although the other etiologies can have similar imaging findings, spinal meningitis is the best explanation for the acute onset presentation of this patient's symptoms.
True
Oftentimes, there are no imaging findings seen in early spinal meningitis
True
Transient hydrocephalus
Transient hydrocephalus is the most common complication of meningitis but usually has no long-term complications, provided the patient receives early effective treatment
MRI shows meningeal irritation extending into the cervical and thoracic areas and also meningeal enhancement.
MR示颈胸段水平脊膜增厚，增强扫描可见强化。
Diagnosis
Spinal meningitis 脊膜炎
The patient received a lumbar puncture, which showed white blood cell count in the 300s and was confirmed to have methicillin-resistant Staphylococcus aureus (MRSA) bacteremia on blood culture.
患者腰椎穿刺，结果显示白细胞计数异常*，血培养为耐甲氧西林金黄色葡萄球菌（MRSA）败血症。
*:The normal white blood cell count range is 4300-10,800 white blood cells per cubic millimeter (cmm) of blood.但in the 300s到底是多少，小编也不太清楚。有知道的微友可以告诉我，直接给平台发消息就能收到。
Spinal meningitis
脊膜炎
In this case, MRI showed meningeal irritation extending into the cervical and thoracic areas. Of note, diffuse, extensive subarachnoid enhancement is a good diagnostic clue. Typical MR findings on T1-weighted imaging includes increased cerebrospinal fluid (CSF) intensity, indistinct cord-CSF interface, irregular cord outline, and clumped nerve roots. On T2-weighted imaging, findings include obliterated subarachnoid space and nodular or band-like filling defects in the subarachnoid space, as well as hyperintense cord signal. On T1-weighted imaging contrast-enhanced images, findings include smooth or nodular meningeal enhancement, such as seen in this case. MRI is recommended as the best imaging modality for spinal meningitis, although CT also has been successfully utilized.
本病例中，MR示颈胸段脊膜反应性增厚，增强扫描软脊膜下弥漫性强化是一个重要的诊断线索。MR典型表现为T1WI脑脊液信号增高，脑脊液-脊髓分界不清，脊髓边缘毛糙，神经根纠结成簇；T2WI表现包括蛛网膜下腔闭塞，蛛网膜下腔内结节状或带着充盈缺损，脊髓信号增高。增强扫描T1WI，脊膜均匀或结节状强化。
尽管CT也可用于诊断脊膜炎，但一般认为MR是诊断脊膜炎最好的影像学检查。
Neurosarcoidosis was a consideration for this case as the patient has a history of sarcoidosis. On MRI of neurosarcoidosis, T1-weighted imaging findings include hydrocephalus and lacunar infarcts. Additionally, there can be cord enlargement or cord atrophy, depending on stage of disease progression. Lesions typically present iso- to hypointense on T1-weighted imaging. On T2-weighted imaging, findings include hypo- or hyperintense meningeal foci. Of note, approximately 30% of neurosarcoidosis cases have leptomeningeal involvement. Typically, neurosarcoidosis presents in patients with systemic disease. Usually, in such cases, chest radiographs appear abnormal more than 90% of the time.
由于该患者有肉样瘤病病史，所以需要考虑神经肉瘤病的可能。神经肉瘤病的T1WI表现包括脑积水及腔隙性脑梗塞，根据病程不同脊髓可增粗或萎缩，病灶一般为等或略低信号。T2WI表现脊膜局灶性低信号或高信号。
约30%的肉样瘤病可累及软脊膜，引起全身症状，此时，超过90%的患者胸部X线会有异常表现。
Leptomeningeal carciomatosis also was considered in this case. Typical findings on T1-weighted imaging include usually isointense signaling in the cord or roots, depending on the site of metastasis. Nerve roots may appear “blurred” and CSF can have a hazy appearance. T2-weighted imaging findings include thickened nerve roots or iso- to hyperintense signaling in the cord or nerve roots. Clinically, however, the patient was asymptomatic, had all age-appropriate screening done, and had no other known sources for possible metastasis.
本例中，软脊膜转移性病变同样应作为鉴别诊断。转移瘤在T1WI根据病变位置不同表现为脊髓或神经根等信号病灶，神经根与CSF边界不清。T2WI可见神经根增粗，脊髓或神经根内见等至高信号。
临床上，本例患者没有响应的症状，且没有明确的原发肿瘤病史。
Although other etiologies were included in the differential diagnosis, they remained lower on the differential as the patient did not clinically have signs correlating to other pathologies.
也有其他部分病因需要作为鉴别诊断，但本例临床上与其他病因关系不大。
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