Brain Tuberculoma as a Differential Diagnosis of Single Intracranial Lesion: Case Report

Tuberculosis (TB) of the central nervous system (CNS) is considered one of the most severe forms of presentation of the disease. Although only 1% of TB cases involve the CNS, these cases represent around between 5 and 15% of extrapulmonary forms.1,2 Tuberculous meningitis (TBM) is the most frequent form of CNS TB. The granulomas formed in the cerebral tuberculoma may cause hydrocephalus and other symptoms indicative of a CNS mass lesion. In the absence of active TB or TBM, the symptoms may be interpreted as indicative of tumors.3,4 The prognosis is directly related to the early diagnosis and proper treatment installation.5 We report the case of a patient with intracranial hypertension syndrome, expansive mass in the parieto-occipital region, accompanied by a lesion in the rib, initially thought to be a metastatic lesion, although posteriorly diagnosed as a cerebral tuberculoma.

Tuberculosis cerebral sin meningitis en un niño inmunocompetente / Cerebral tuberculosis without meningitis in a immunocompetent child

Resumen La tuberculosis (TBC) cerebral o tuberculoma(s) sin meningitis es una enfermedad poco frecuente y de alta morbimortalidad. Presentamos el caso clínico de un lactante de 11 meses, previamente sano, que consultó por fiebre prolongada y síntomas neurológicos. La RM de encéfalo mostró múltiples imágenes micronodulares e hidrocefalia. El estudio de LCR para bacterias, hongos y micobacterias fue negativo. Se prescribió terapia empírica como una meningoencefalitis subaguda y tratamiento antituberculoso tetraconjugado y corticoesteroides. La confirmación del diagnóstico de TBC cerebral se realizó por biopsia de la lesión, con presencia de inflamación granulomatosa crónica necrosante y bacilos ácido-alcohol resistentes. Se enfatiza la importancia de considerar esta presentación de TBC en niños, y la necesidad de la búsqueda exhaustiva del agente etiológico en diferentes líquidos y tejidos, aun por métodos invasores.

Cerebral tuberculosis TB (tuberculomas) without meningitis is an uncommon disease with a high morbidity and mortality. We report on a case that illustrates the complexity of this clinical presentation. An 11 month old, previously healthy male infant was brought to the clinic due to fever present during the last 1.5 months, associated with loss of neurodevelopmental goals and signs of endocranial hypertension. CT scan of the skull revealed dilatation of the ventricular system with transependimary edema; MRI showed multiple intra- and extra-axial micronodular images and hydrocephalus. Studies of CSF (cyto-chemical analysis, staining, culture for aerobes, fungi, mycobacteria, and molecular tests for TB were negative). Empirical management for subacute meningoencephalitis was prescribed complemented with tetraconjugated treatment for TB and steroids. As there was no microbiological isolation, biopsy of a cerebellar lesion was performed, which revealed chronic necrotizing granulomatous inflammation and acid-alcohol resistant bacilli. The diagnosis of cerebral TB without meningeal involvement was confirmed. The objective of the present report is to emphasize the importance of considering this presentation of TB in children, to remark the need of exhaustive search for the etiologic agent by obtaining samples of the different fluids and tissues even if it implies recurring to invasive methods.

Comparison between solitary and multiple intracranial tuberculoma

To compare and analyze the clinical, radiological, and pathological features of solitary or/and multiple CNS tuberculomas [CNSTs]. The study was conducted at Central South University, First Xiangya Hospital, Changsha, Hunan, China between 1998-2008. Forty-two subjects with diagnosed CNSTs were compared and analyzed by multiple or solitary lesions seen on enhanced MRI. The final diagnosis of tuberculomas was confirmed by histopathology. From the 42 subjects, 64.3% multiple CNSTs were observed, out of which, 55.6% were with meningitis and 44.4% without meningitis. Of the CNSTs, solitary lesions were present in 35.7%, 80% of which were without meningeal involvement, and 20% with meningeal involvement. In multiple CNSTs, 55.6% were noncaseating granulomas, and 74.1% caseating granulomas with a solid center, while in solitary CNSTs, 80% were caseating granulomas with a solid center. For multiple lesions, temporal lobe, frontal lobe, cerebella, and brain stem were predilection sites. While for solitary lesions, apical lobe, and cerebellum were predilection sites. The histopathological features were the same in all multiple and solitary lesions. Multiple CNSTs are more often associated with meningitis, while solitary CNSTs particularly occur with less or atypical clinical manifestation. Difference in the predilection sites between multiple and solitary CNSTs were observed

Cranial computed tomography in partial motor seizures.

OBJECTIVE: To identify the pattern of intracranial structural lesions in developmentally normal children with partial motor seizures by computed tomography and to monitor the behavior of single ring enhancing lesion (SREL) after a period of time with or without treatment. METHODS: Consecutive developmentally normal children between one year and twelve years with partial motor seizures in a tertiary care referral Hospital. After clinical examination and appropriate investigation for tuberculosis and cysticercosis, CT scan was performed. In addition to anticonvulsants, children received antituberculous or anticysticercal therapy if indicated. Repeat CT was performed on children with SREL after 6 months. RESULTS: Computed tomography was abnormal in 102 (68%) children. Majority of the children (75) had SREL. The lesions were located in decreasing order of frequency in the parietal lobe (65), frontal lobe (7), occipital lobe (1), temporal lobe (1) and cerebellum (1). Repeat CT scan was performed on 50 of the 75 children with SREL. Among these, in 41 children who were only on antiepileptic therapy, the SREL had decreased in size in thirty-two whereas in the rest (9), there was no change in the size. CONCLUSION: Awareness of the existence of disappearing SREL lesions is essential to avoid unnecessary treatment with antituberculous or anticysticercal therapy and provides ample justification in treating with anticonvulsant drugs only.

Tuberculoma cerebral / Cerebral tuberculoma

Relata-se o caso de paciente com crises convulsivas de início recente. A tomografia computadorizada cerebral evidenciou imagem sugestiva de lesão expansiva metastática frontoparietal direita. A investigação de tumor primário ou outra doença foi negativa e o exame histopatológico do tecido cerebral diagnosticou tuberculoma. As convulsões foram controladas com a associação de hidantoína 300mg/dia ao esquema específico, utilizado por 18 meses. A tuberculose do sistema nervoso central representa 5-15 por cento das formas extrapulmonares e é reconhecida como de alta letalidade. Apresentação tumoral como a relatada é rara, particularmente em imunocompetentes. Quando tratada, pode ter bom prognóstico e deve entrar sempre no diagnóstico diferencial de massas cerebrais

Neurocysticercosis like presentation in a case of CNS tuberculosis.

A clinical picture consisting of seizures, multiple non-tender subcutaneous nodules, and multiple 'nodular or ring' enhancing lesions in computed tomography of the brain is considered characteristic of neurocysticercosis in an endemic area. 1,2 A case with a similar clinical picture, in whom serological tests and histopathological examination of subcutaneous nodule established tuberculosis as a cause, is presented.

Tuberculomas biliares de la tienda del cerebelo asociados a neuralgia del trigémino: informe de un caso / Bilateral tuberculomas of the tentorium associated with trigeminal neuralgia: a case report

La neuralgia del trigénio (NT) se asocia con múltiples lesiones intra y extracraneanas como son la compresión vascular arterial o venosa, ateroesclerosis, esclerosis múltiple, malformaciones arteriovenosas, etc. Se piensa que algunas de estas lesiones intervienen en la patogenia de la NT. Se presenta el caso de una mujer de 72 años con NT unilateral secundaria a la presencia de tuberculomas bilaterales de la tienda del cerebelo, y del surco olfatorio. Murió como consecuencia de leptomeningitis tuberculosa. Se revisan los conceptos actuales de la patogenia de la NT

In vivo localized proton magnetic resonance spectroscopy of intracranial tuberculomas.

In vivo proton magnetic resonance spectroscopy (MRS) was performed in ten patients with intracranial tuberculomas with the aim of finding biochemical finger prints which may help in the noninvasive diagnosis of the disease. Diagnosis of tuberculoma was confirmed in all these cases retrospectively. Ex vivo spectroscopy of formalin fixed samples of four granulomas and a normal brain (cerebellar) tissue, was performed to confirm the in vivo resonances. The in vivo study showed resonance at 1.3 ppm and 0.9 ppm assigned to methylene group (CH2)n and terminal methyl groups (-CH3) of fatty acids respectively which was subsequently confirmed by the ex vivo study. Large resonances of fatty acids in in vivo study appeared to be due to high lipid content of caseous material. It is concluded that in vivo proton spectroscopy may be helpful in differentiating tuberculomas from other intracranial mass lesions which have diagnostic difficulties on MR imaging.

Tuberculomas cerebrais / Cerebral tuberculomas

A tuberculose do sistema nervoso central é uma doença encontrada em todo o mundo, principalmente nos países subdesenvolvidos. No final do século passado, a incidência de tuberculomas era alta entre as lesoes expansivas intracranianas, mesmo em países desenvolvidos. Esta incidência caiu acentuadamente (de 30 para 3 por cento) na metade deste século, devido à introduçao da estreptomicina, e a tuberculose praticamente desapareceu nos países desenvolvidos nas décadas de 50 e 60. Posteriormente,casos esporádicos começaram a surgir, principalmente entre imigrantes. No Brasil, casos clínicos isolados de tuberculomas intracranianos têm sido descritos, mas eles constituem aproximadamente 5,5 por cento dos processos expansivos intracranianos observados em necrópsias. Neste trabalho, foram analisadas retrospectivamente as evoluçoes clínicas de sete pacientes portadores de tuberculomas cerebrais atendidos no Serviço de Neurocirurgia do HCFMRP, no período de 1979 a 1991. O diagnóstico de tuberculoma cerebral foi efetuado com base nos exames neuroradiológicos (radiografia simples e tomografia computadorizada), associados a antecedentes de meningite tuberculosa ou tuberculose extraneural, em cinco pacientes (três confirmados com exame histopatológico) e em dois, através do exame histopatológico da peça cirúrgica. Os sinais e sintomas mais freqüentemente observados foram os de hipertensao intracraniana e os de compressao/irritaçao do parênquima cerebral. Um paciente foi tratado apenas clinicamente com esquema tríplice (isoniazida, rifampicina e etambutol) e apresentou boa evoluçao. Três pacientes foram submetidos à exérese total ou subtotal da lesao e dois foram submetidos à exérese parcial da lesao e à DVP e um paciente foi submetido apenas à DVP. Para todos os pacientes, foi indicado tratamento com tuberculostáticos, embora um paciente nao o tenha completado. Os três pacientes que foram submetidos à exérese total da lesao, um dos pacientes submetidos à exérese parcial da lesao e à DVP e o paciente submetido apenas à DVP apresentaram boa evoluçao, com regressao e/ou calcificaçao das lesoes, com ou sem seqüelas neurológicas moderadas. O outro paciente submetido à ressecçao parcial e à DVP evoluiu mal e faleceu. Para os pacientes com tuberculomas intracranianos, indicamos inicialmente o tratamento clínico; o tratamento cirúrgico é indicado quando há hidrocefalia com hipertensao intracraniana, quando a lesao exerce efeito de massa importante, quando nao há resposta ao tratamento clínico ou quando há dúvida quanto ao diagnóstico.