Bombay Hospital Journal, Vol. 54, No. 2, 2012
Introduction
r i n g e n h a n c i n g l e s i o n o n Aradioimaging is always a matter of
confusion between neurocysticercosis and
tuberculoma especially in Indian
population where both the things are
common. Usually if lesions are multiple
w i t h c a l c i f i c a t i o n t h e y a r e
neurocysticercosis, however it is usually
crosschecked on the basis of history,
c l in ical f indings and other lab
investigations and the diagnosis is always
based on cumulative results.
Case Report
A 28 year old on mixed diet came with complains of
1. low grade on and off fever since 4 months
2. Inability to move both the eyes on right side
since 10 days
3. Deviation of mouth to the left since 10 days
4. Dull aching generalised headache since 10 days.
There is no history of significant weight loss or
loss of appetite
There is no past history or family history of
tuberculosis.
On examination
Patient was absolutely conscious and oriented
with normal vitals.
No lymphadenopathy or soft tissue palpable
mass s/o soft tissue cystecerci.
Fundoscopy was not suggestive of papiloedema
A Case of Multiple Brain Parenchymal Tuberculoma
Anannya A Mukherji*, Alok A Shah**, Santwana D Chandrakar***
*Professor and Unit Head, **Junior Resident, ***Associate Professor, Department of Medicine. Dr. D. Y. Patil Medical College. Nerul
Abstract
We report a case of 28 year old male with relatively clinically silent multiple ring
enhancing lesion which was diagnosed as multiple brain parenchymal tuberculoma
and treated on the same line.
or ocular cysticerci.
Chest was absolutely clear.
On CNS findings were suggestive of right sided
lower motor neuron type of facial palsy and right
sided gaze palsy with horizontal nystagmus.
Investigations
Hb-15 gm/dl
Total count -12000/ul with neutrophilia
Eosinophil-2%
Fasting ESR -70 mm at end of one hour
Elisa for HIV was negative
Anticysticercal antibody turned negative
Stool routine and microscopy was not suggestive of
ova/cyst
Chest X-ray normal
All X-ray of soft tissue not suggestive of soft
tissue calcifications.
MRI was suggestive of multiple brain
parenchymal tuberculoma as in the photograph.
Fig. 1 : MRI images prior to treatment
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Bombay Hospital Journal, Vol. 54, No. 2, 2012
Fig. 2 : MRI images after the treatment
of repeat admission
Patient was started with
Injectable mannitol, injectable dexamethasone,
four drugs anti tubercular therapy which included
rifampicin, isoniazid, ethambutol, pyrazinamide and
pyridoxine. Phenytoin, folic acid was also started in
view of the multiple numbers of lesions as
prophylactic anti epileptic. He was hospitalised for 5
days and discharged with oral steroids with tapering
schedule, ATT, antiepileptic, folic acid and
pyridoxine. Subsequently after one month patient
developed paradoxical symptoms of raised
intracranial tension, with headache and vomiting,
though the repeat MRI showed improvement in the
lesions Patient ultimately finished full course
ATT and no admissions required then.
Discussion
The incidence of intracranial
tuberculomas varies from country to
country, ranging between 0.5% and 30.5%
of all brain tumours, and those involving 1the brain stem ranges from (0 to 4.3%).
Though mult ip le intracrania l
tuberculomas are seen in autopsy
findings, they are comparatively rarely
seen clinically. The highlight of this case is
that the despite the brain being studded
with multiple tuberculomas, the patient
was comparatively asymptomatic and had
features of only brain stem involvement in
the form of a horizontal gaze palsy and a
mild lower motor neuron facial palsy.
T u b e r c u l o m a i s a p e c u l i a r
manifestation of tuberculosis which
occurs in any solid organ of the body. It is
usually formed by conglomeration of
several miliary tubercles, which form
around the outer sheaths of the small
cerebral blood vessels. The centre of the
conglomeration becomes caseous.
Caseous material gets inspissated and
sometimes liquefied. A thick capsule may 1form around these lesions.
Intracranial tuberculomas occur most
commonly in the cerebral and the
cerebellar hemispheres, which have
relatively profuse blood supplies.
Presence of gaze palsy, as the only
manifestation is relatively rare in the
English literature. Tuberculoma is
characterised by its clinical heterogeneity,
which particularly depends on the variable
location, size and number of the
tuberculomas. Lisa and Deangelis
emphasise the high frequency of seizures
(50%-80%), but intracranial hypertension 2or neurologic deficit can also be seen.
Unlike malignant tumours of the
central nervous system, tuberculomas
often grow without permanently
destroying the surrounding neural tissue,
thus enabling good clinical recovery.
However, tuberculomas may rupture into
the subarachnoid space, causing
meningitis, vasculitis, diffuse cerebral 3oedema, and hydrocephalus.
Usually brainstem tuberculoma
presents with low grade fever, weight loss,
vomiting, sixth and seventh cranial nerve
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Bombay Hospital Journal, Vol. 54, No. 2, 2012
affection along with motor and sensory
symptoms which are usually unilateral.
Isolated cranial nerve palsies are often
attributed to lesions of the respective
nerves along their extra axial courses.
However, ischaemic or haemorrhagic
lesions of the brainstem also cause
isolated cranial nerve palsies through
involvement of the intra axial segments of 4the respective nerves.
Diagnosis is usually confirmed by CT
scan brain (plain and contrast) and by
MRI. In a study done by Wasey et al , who
studied more than 100 cases of
tuberculoma he found the following
findings on CT Scan, that the size
(diameter) of these lesions ranged from 1
mm to 5 cm. Eighty-six per cent of the
lesions were < 1 cm, 11% of the lesions
were 1 to 3 cm, and 3% of the lesions were
> 3 cm in diameter. On noncontrast head
CT scans, 90% of the lesions were isodense
to brain parenchyma, 7% were
hyperdense, and 3% were hypodense. The
pattern of enhancement was dependent
upon the size of the lesion. More than 90%
of the lesions < 3 mm in size showed
homogenous enhancement. Sixty per cent
of the lesions ranging from 0.3 to 1 cm in
size were ring enhancing, whereas 40%
showed homogenous enhancement.
Lesions > 1 cm in size showed varied
enhancement, including irregular shapes,
ring like shapes, open rings, and lobular
patterns. Target like lesions were seen in
only 2 patients. Calcification was present
in < 10% of the lesions. Sixteen patients
had both CT and MRI scans. CT scans
were more sensitive in the diagnosis of
calcification, where as MRI scans were
more sensitive in picking up a larger
number of lesions, infarcts, vasogenic 5oedema, and meningeal enhancement.
Our patient was started on four drug
antituberculous therapy with steroids
which emphasise the efficiency of steroids
in reducing the perilesional oedema and
threatening intracranial hypertension.
Anticonvulsant treatment is mandatory
for seizure control. The indication of
medical treatment alone is justified 5because it is safe, efficient, and cheap. In
conclusion, patients, who are suspected to
be suffering from CNS tuberculosis should
receive a prolonged (12-30 months) course
of effective antituberculous therapy. Our
patient developed severe headache with
vomiting after almost one month of
therapy, though the repeat MRI shows a
reduction in the size of the tuberculomas.
The possible immunological mechanisms
of this phenomenon are analysed.
E v i d e n c e o f n e w i n t r a c r a n i a l
tuberculomas or the expansion of older
existing lesions requires no change in the
antituberculous drug programme. In such
cases systemic dexamethasone as
adjuvant therapy for 4 to 8 weeks is 6worthwhile and effective.
References
1. Bhasakara Reddy D. AND Kameshwara Rao V.
Tuberculoma of the brain. Indian Journal of
Tuberculosis 1951 ; 2 (2): 93-98.
2. Lisa M, Deangeli S. Intracranial tuberculoma:
Case Report And Review of the Literature.
Neurology 1981; 31: 1133-1136.
3. Mohamed Maftah, Ali akhaddar, M Lmjjati, A
mansouri, Najia EL Abbadi, Foud Bellakhdar.
Intracerebral tuberculoma: (Report of 115 cases)
The Pan Arab Journal of Neurosurgery 2001; 5 :
1-50
4. C.M.Sharma, B.L.kumawat. Isolated sensory
trigeminal neuropathy - A rare clinical
presentation of brainstem tuberculoma: The
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Internet Journal Of Neurology 2009; 11:
Number 1
5. Wasay M, Kheleani BA, Moolani MK, ET AL.
Brain CT And MRI Finding in 100 consecutive
patients with intracranial tuberculoma :
Journal Of Neuroimaging 2003; 13: 240-247
6. Hejazi N, Hassler W, Rappaport Z. H. Multiple
intracranial tuberculoma with atypical response
to tuberculostatic chemotherapy. Acta
Neurochirurgica 1997; 139 : 194-202
Letters to Editor
Xpert MTB/RIF test for tuberculosis
Xpert MTB/RIF has been specifically recommended by WHO as a frontline diagnostic test in individuals and HIV co-infection. Although Xpert MTB/RIF comprehensively outperforms smear microscopy, and is thus a substantial advance over the standard of care in people with HIV infection, these data highlight the need to treat a single negative result in people with HIV infection with caution.
G. Theron, J. Peter, K. Dheda, The Lancet, 2011; Vol. 378;481
We assessed the Xpert MTB/RIF test in 90 patients with suspected pulmonary tuberculosis in a high-prevalence region of Dharamsala, India.
In seven cases, Xpert MTB/RIF identified rifampicin resistance that was not confirmed by conventional DST.
The Xpert MTB/RIF test for rifampicin resistance requires further development to achieve 100% specificity.
F. Salvo, T. Sadutsang, G. Migliori, A. Zumla, D. Cirillo, The Lancet, 2011; Vol. 378;481
We need to move on and assess its cost-effectiveness and how it will change the performance of national tuberculosis programmes in terms of detection rates and management of resistant forms of Mycobacterium tuberculosis.
Although the Xpert MTB/RIF assay is recommended for screening of drug-resistant tuberculosis and for populations infected with HIV, its high sensitivity in smear-negative cases could support other uses, such as for biomarkers of tuberculosis disease activity or cure.
G. Ferrara, J. Grady, A. Zumla, M. Maeurer, The Lancet, 2011; Vol. 378;482
Author's reply
Since no test is 100% sensitive, health workers confronted with negative results from patients with suspected disease must: (1) retest a new sample, (2) test with alternative methods, or (3) treat on
clinical bases. Xpert despite sensitivity similar to solid culture, cannot resolve this dilemma.
Fulvio Salvo and colleagues stress that the need for phenotypic drug susceptibility testing (DST) will
not disappear with Xpert implementation.
Both phenotypic and genotypic testing result in some false calls: errors in DST for rifampicin occur with a frequency of 1-3% even in supranational laboratories.
Ideally, Xpert should equal or surpass DST reliability.
Mark D Perkins, David Alland, Mark P Nicol, Pamela Nabeta, Catharina C Boehme, The Lancet,
2011;Vol. 378;481-483
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