I saw a different "bunch of grapes" sign in two patients with neurotuberculosis

Neurotuberculosis is one of the most severe forms of tuberculosis, often posing diagnostic challenges due to its variable imaging presentation. We report two cases demonstrating the characteristic "bunch of grapes" sign on brain magnetic resonance imaging (MRI), representing coalescent ring-enhancing tuberculomas. The first patient was a 44-year-old woman presenting with fever and aphasia, while the second was a 28-year-old HIV-positive woman on irregular antiretroviral therapy with a history of impaired gait, dizziness and nausea. MRI revealed multiple T2-hypointense nodular lesions with ring-like gadolinium enhancement forming grape-like clusters. Stereotaxic biopsy confirmed central nervous system tuberculosis in both cases. Standard antituberculous therapy combined with corticosteroids led to progressive clinical improvement. Recognition of the "bunch of grapes" appearance can facilitate early diagnosis of neurotuberculosis and guide appropriate treatment, particularly in endemic regions where overlapping imaging findings with other infectious or neoplastic diseases may occur.