- Neuro-melioidosis often causes extensive craniospinal disease with disproportionate brainstem, tract-based (CST) and spinal involvement; tunnel sign seen in 57.6%.
- MRI commonly shows multifocal lesions, diffusion restriction in 72.7% and SWI haemorrhage or microbleeds in 36.4%, aiding diagnosis.
- Initial misdiagnosis occurred in 24.2% and 30.3% received steroids pre-diagnosis; recognise imaging pattern and confirm with blood, tissue or CSF culture.
AJNR Am J Neuroradiol. 2026 Aug 19:ajnr.A9601. doi: 10.3174/ajnr.A9601. Online ahead of print.
ABSTRACT
BACKGROUND AND PURPOSE: Neuro-melioidosis is an uncommon but potentially fatal manifestation of Burkholderia pseudomallei infection with diverse and often under-recognized imaging features. Existing imaging literature is limited to isolated reports and small series. We aimed to characterize the craniospinal MRI spectrum of neuro-melioidosis in a multicentre Indian cohort and identify recurrent imaging patterns associated with diagnostic delay.
MATERIALS AND METHODS: In this retrospective multicentre case series, 33 patients with microbiologically confirmed neuro-melioidosis from seven Indian tertiary centres (2019-2025) underwent systematic neuroimaging review using a pre-defined data-collection template containing 40-variables. MRI features including lesion distribution, tract involvement, diffusion restriction, susceptibility abnormalities, enhancement patterns, meningeal disease, and spinal involvement were analysed descriptively alongside clinical and microbiological data.
RESULTS: Supratentorial involvement was present in 81.8% (27/33), infratentorial disease in 60.6% (20/33), and multifocal lesions in 60.6% (20/33). Brainstem involvement occurred in 57.6% (19/33). White matter tract dissemination was identified in 66.7% (22/33), with CST involvement in 63.6% (21/33); the “tunnel sign” was observed in 57.6% (19/33). Spinal involvement was present in 42.4% (14/33), including simultaneous brainstem and intramedullary disease in 33.3% (11/33). Diffusion restriction occurred in 72.7% (24/33), while SWI demonstrated haemorrhage or microbleeds in 36.4% (12/33). Initial misdiagnosis occurred in 24.2% (8/33), and 30.3% (10/33) received corticosteroids before definitive diagnosis. In-hospital mortality was 12.1% (4/33).
CONCLUSIONS: Neuro-melioidosis produced extensive craniospinal disease with a disproportionate frequency of brainstem, tract-based, and spinal involvement relative to other bacterial CNS infections. Recognition of this pattern together with blood, tissue, and/or CSF culture, which remain the diagnostic standard, may facilitate earlier diagnostic consideration and targeted microbiological evaluation in endemic settings.
PMID:42618339 | DOI:10.3174/ajnr.A9601
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