Granulomatous hypertrophic spinal pachymeningitis is an exceptionally rare cause of compressive myelopathy. We report a 45-year-old woman with a 5-month history of progressive quadriparesis, neck pain, and sensory impairment. Neurological examination revealed spastic quadriparesis with posterior column dysfunction and preserved cranial nerve and sphincter function. Magnetic resonance imaging demonstrated multilevel cervicothoracic dural thickening (C2–D4) with T2 hypointensity and diffuse enhancement, features considered suggestive of tuberculous pachymeningitis. Cerebrospinal fluid analysis showed markedly elevated protein (834 mg/dL) with normal glucose and lymphocytic predominant cytology. Dural biopsy revealed granulomatous inflammation without malignancy. Tissue GeneXpert and microbiological studies were negative; however, molecular assays in paucibacillary extrapulmonary samples have reported sensitivities of approximately 60%–70%, limiting their rule-out value. The patient was treated with intravenous followed by oral corticosteroids and antitubercular therapy for 1 year, with significant improvement in motor power, gait, and pain. Fewer than 50 cases of spinal hypertrophic pachymeningitis have been reported worldwide.
Pavai et al. (Thu,) studied this question.