Fatal hemorrhagic intracranial TB in a renal transplant recipient despite INH prophylaxis

A 50-year-old ESRD who received LUR renal graft abroad. Since transplanted, he remained dependent on hemodialysis. The patient received steroid pulse therapy twice for rejecrion. Nonspecific bilateral lung infiltrate were noted on admission CXR, which stimulated the search for TB. The patient suddenly lost consciousness during his hospital stay. Intracranial hemorrhage was drained and tissue staining revealed heavy loads of tuberculus (TB) bacilli. The patient died two weeks later from septic shock with multi-organ failure.

Calvarial tuberculosis: an unusual presentation (2007: 8b)

We describe a case of calvarial tuberculosis with an associated extra-dural collection. This presentation has rarely been reported in the literature and the magnetic resonance imaging features are not well documented.

Multiple intracranial tuberculomas in an HIV-negative 28 year old male--a case report

Intracranial tuberculomas are uncommon complications of tuberculosis, especially in immuno-competent individuals with no evidence of extra-cranial foci. We report a case of an HIV- negative young male who presented with presumed cerebral and cerebellar tuberculomas without identifiable extra-cranial focus. The CT scan revealed multiple intracranial ring-enhanced lesions. The remarkable response to antituberculous drugs and steroid (prednisolone) with near complete resolution of clinical and radiological signs was highly suggestive of diagnosis. In the differential diagnosis of intracranial mass lesions in sub-Saharan Africa, a high index of clinical suspicion is needed to avoid misdiagnosis of intracranial tuberculoma.

Multiple intracranial tuberculomas mimicking granulocytic sarcomas in acute myeloid leukemia

The diagnosis of incracranial tuberculoma in immune-compromised hosts is often difficult because conventional magnetic resonance (MR) imaging of tuberculoma reveals various findings and neurologic symptoms are not typical. Here, we report a case of a 54-yr old man with multiple intracranial tuberculoma who was treated for acute myeloid leukemia. He complained of right-side paresthesia after the third consolidation chemotherapy without leukemic relapse and fever. MR imaging of the brain showed multiple ring-enhanced lesions in the cerebrum, cerebellar hemisphere, and pons. The lesions appeared to mimic a metastatic tumor or abscess. Cerebrospinal fluid analysis showed no abnormal cells, but the level of adenosine deaminase was elevated (28.8 IU/L, normal 0-8). Stereotactic brain biopsy was performed, but only reactive gliosis was observed. To confirm diagnosis, an open brain biopsy was performed. The histopathology demonstrated chronic granulomatous inflammation with caseous necrosis. Tuberculous-polymerase chain reaction of the biopsy showed a positive result. He was treated with anti-tuberculosis medication and a high dose of steroid. Paresthesia improved, and follow-up brain MR imaging showed the decreased size and numbers of ring-enhanced lesions and improvement of perilesional edema 1 month after treatment. Here, we report on an interesting case of intracranial tuberculoma in acute myeloid leukemia.

Meckel's Cave Tuberculoma with Unusual Infratemporal Extension

The authors describe a rare case of intracranial tuberculoma of the Meckel's cave and cavernous sinus with extension into the infratemporal fossa causing widening of the foramen ovale and adjacent bone destruction. The rarity of the lesion and the unusual extension of the lesion are presented with a brief review of literature.

Pituitary tuberculosis

Tuberculous involvement of pituitary is extremely rare and is usually not suspected while dealing with pituitary adenomas, even in patients with history of systemic tuberculosis. We report a case of pituitary tuberculoma in a patient who was undergoing treatment for prostatic tuberculosis. Although diagnosis of sellar tuberculomas is difficult on clinical and radiological examinations, pituitary tuberculomas should be considered in the differential diagnosis of suprasellar masses, especially in developing countries as the condition is potentially curable with antituberculous treatment.

T2 relaxometry of ring lesions of the brain

AIM

To differentiate two common aetiologies of "ring lesions," tuberculomas and cysticercal cysts, using T2 relaxometry.

MATERIALS AND METHODS

Fifty-five ring-enhancing lesions of the brain (32 cysticercal cysts; 23 tuberculomas) in 27 patients with focal seizures were studied for T2 relaxation times.

RESULTS

The mean T2 relaxation times of cysticercal cysts was 617 ms (range 305-1365 ms; SD 272.2) and that of tuberculomas 161 ms (range 83-290 ms; SD 60.3; 95% confidence).

CONCLUSION

T2 relaxometry is a simple, reliable and valuable non-invasive magnetic resonance imaging (MRI) technique to differentiate between intracranial cysticercal cysts and tuberculomas, and may be incorporated in routine diagnostic protocols.

Disseminated tuberculosis with multiple intracerebral tuberculomas in a patient with anorexia nervosa

OBJECTIVE

Multiple tuberculous mycobacterial infections infrequently occur in immunocompromised patients. The malnutrition resulted from anorexia nervosa may contribute to the significant impairment of immunity. The authors present a 23-year-old female patient initially diagnosed with anorexia nervosa.

METHOD

Immunological study revealed that helper T-cell (CD4) and cytotoxic T-cell (CD8) comprised 25 and 32%, respectively, with a CD4 to CD8 ratio of 0.78. Brain magnetic resonance imaging revealed various multiple rings enhancing lesions with edematous change in both cerebral and cerebellar hemispheres.

RESULTS

Open biopsy disclosed palisading epithelioid granuloma surrounded by inflamed granulation tissue. After anti-tuberculous therapy for 12 months, her weight was completely restored, but multiple intracranial tuberculomas were not completely disappeared.

CONCLUSION

Disseminated tuberculous mycobacterial infections including multiple intracranial tuberculomas may be attributed to immunocompromised status in anorexia nervosa.

[Diagnostic image (309). An Indonesian woman with headache, confusion and fever]

A 30-year-old Indonesian woman presented with headache, confusion, vomiting, diplopia and fever, due to multiple intracranial tuberculomata.

Pontine tuberculoma presenting with horizontal gaze palsy

A 38-year-old immunocompetent man presented with a horizontal supranuclear gaze palsy as the only neurologic manifestation of a pontine tuberculoma. Although a biopsy of the brain lesion was not performed, it was attributed to tuberculosis because of chest x-ray evidence. The patient was given empirical anti-tuberculous therapy. After one month, the gaze palsy had fully recovered and repeat MRI showed a decrease in the size of the lesion. This is the first reported case of supranuclear gaze palsy without diplopia as a manifestation of a tuberculous brain stem lesion.

Cerebral tuberculoma presenting as flexion spasms

A 10-month-old girl was admitted with refractory infantile spasms. Video EEG demonstrated focal epileptic activity, and MRI revealed a conglomeration of annular lesions. Surgical excision was performed and pathology was consistent with tuberculoma. After antituberculous therapy, the outcome was favorable. Despite all investigations, Mycobacterium tuberculosis's mode of transmission was unclear, and both congenital and postnatal acquired forms were considered.

Tuberculoma of the brain: a series of 16 cases treated with anti-tuberculosis drugs

OBJECTIVES

To describe the clinical presentation, radiological findings and outcome of treatment with antituberculosis drugs in 16 cases of intracranial tuberculoma.

DESIGN

Consecutive cases admitted with tuberculoma to the National Center for Neurological Diseases in Khartoum, Sudan, were included in the study. The diagnosis was based on clinical and neuro-imaging features and response to anti-tuberculosis treatment. Histopathology of material from the brain or other extracranial tissues was available in seven cases.

RESULTS AND CONCLUSIONS

The commonest presenting features were headache (100%), generalized convulsions (68.7%) and hemiparesis (56.2%). Computerised axial tomography/magnetic resonance imaging (CT/MRI) showed single or multiple lesions that showed intense contrast enhancement and perilesional edema. The lesions completely cleared on anti-tuberculosis treatment in the majority of survivors (13/15). Partial clearance of lesion was associated with late presentation, multiple large lesions and advanced miliary disease. We advocate early empirical trial of anti-tuberculosis drugs for intracranial tuberculoma even after a presumptive diagnosis, particularly in areas where the infection is endemic.

Isolated brain stem tuberculoma presenting with one and a half syndrome

In this report, we describe a patient with left conjugate gaze palsy and internuclear ophthalmoplegia on the opposite gaze one-and-a-half-syndrome [11/2 syndrome]. Magnetic resonance imaging of the brain showed nodular enhancing brain stem lesions. After excluding other potential diseases, tuberculoma was thought to be the underlying etiology. Recovery was achieved 8 weeks after initiation of anti-tuberculous anti-TB therapy. The isolated nature of the tuberculoma and the association with this rare syndrome is highlighted.

MR spectroscopy-aided differentiation: "giant" extra-axial tuberculoma masquerading as meningioma

Tuberculosis is common in the developing world and in developed nations secondary to increasing immunocompromise in the population. It commonly causes meningitis and parenchymal tuberculomas. We present a case of an unusual masslike "giant" extra-axial tuberculoma during pregnancy. Unusual morphology and size at imaging made meningioma a close differential. MR spectroscopy served to complement MR imaging, providing diagnostic confirmation and depicted findings characteristic of a tuberculoma.

[Two case mimicking cerebral tuberculoma in MRI diffusion weighted-images with difficult preoperative diagnosis]

Two cases with a high signal intensity core with laminar structure based on diffusion weighed-images (DWI) mimicking intracerebral tuberculoma were herein reported. Both patients were suspected to have pulmonary tuberculosis in their past history and/or based on chest X-ray findings. DWI demonstrated a high signal intensity core with laminar structure, thus suggesting the presence of an intracerebral tuberculoma. As initial therapy, both patients received anti-tuberculous drugs, however, their symptoms did not improve, and the lesions were observed to have increased in MRI. As a result, a biopsy was carried out to clarify the nature of the disease. A pathological examination showed the former to be a brain abscess while the latter was metastatic carcinoma. In such cases mimicking intracerbral tuberculoma based on DWI, anti-tuberculous drugs are first treatment of choice, however, a biopsy should be performed as early as possible if the medication dose not show a significant response.