Traitement des tuberculoses cérébro-méningées

INTRODUCTION

Tuberculous meningitis and brain tuberculomas are currently rare in the western world but remain serious. Improved outcome requires early recognition and treatment of these conditions.

STATE OF ART

Treatment is usually begun before diagnostic confirmation. Therapeutic principles are now better defined thanks to recent recommendations and studies. Antituberculous therapy begins with two months of a combination of four drugs: isoniazid, rifampicin, ethambutol and pyrazinamid. Then follows a longer phase of bitherapy with isoniazid and rifampicin, lasting at least four months but usually extended to seven or ten months as a precaution. Patients at risk of toxic neuropathy should receive pyridoxine supplementation. Corticosteroids must be systematically added during the first eight weeks of treatment, beginning with high dose before progressive tapering. Hyponatremia is common, often induced by emesis and cerebral salt wasting syndrome. Therefore saline supply rather than water restriction is required. Non-obstructive hydrocephaly can usually be managed with diuretic therapy including acetazolamid, sometimes complemented by serial lumbar punctures. Neurosurgical interventions are rarely needed. Monitoring of treatment tolerance and efficacy is mainly clinical. Central nervous system imaging and cerebro-spinal fluid analysis are only required to explain clinical deterioration.

CONCLUSION

With adequate and prompt anti-tuberculous, anti-inflammatory and supportive treatment, the prognosis of central nervous system tuberculosis can be greatly improved.

Paradoxically Developed Optochiasmatic Tuberculoma and Tuberculous Lymphadenitis: A Case Report with 18-Month Follow up by MRI

We report the first case ofextracranial tuberculous lymphadenitis which paradoxically developed during treatment of intracranial tuberculoma. Our patient, a 15-year-old girl who initially presented with meningitis and intracranial tuberculomas, developed extracranial tuberculomas during treatment for central nervous system tuberculosis. She was followed clinically with cerebrospinal fluid (CSF) studies and magnetic resonance imaging (MRI) at three monthly intervals. Within 18 months of specific antituberculous treatment, the patient had fully recovered. The course and response to therapy are discussed in light of the current literature.

Orbital tuberculoma extending into the cranium

Orbital tuberculoma is not uncommon in the developing countries, but intracranial extension of orbital tuberculoma is extremely rare. Our case, a 14-year-old girl, presented with proptosis and progressive painless diminution of vision eventually leading to loss of vision. MRI showed a mass with peripheral enhancement of contrast, separate from the optic nerve and extending into the cranium through the optic foramen. Early decompression and chemotherapy resulted in marked visual recovery. Histopathology of the excised lesion confirmed tuberculosis. The case is reported to highlight both the rare presentation as well as remarkable visual recovery in a patient with orbital tuberculosis.

[Serial MRI findings of intracranial tuberculomas: a case report and review of the literature]

Intracranial tuberculoma is an infectious disorder, occurring with or without tuberculous meningitis. Although intracranial tuberculoma is rare in developed countries, its frequency has increased in recent years in association with aging and immunocompromised hosts. Because of the low sensitivity of Mycobacterium tuberculosis cultures or of DNA detection from cerebrospinal fluid, diagnosis of intracranial tuberculoma is often difficult. Conventional magnetic resonance (MR) imaging of the tuberculoma yields variable results and is indistinct from other inflammatory lesions or brain tumors. We report the case of a 74-year-old woman with progressive neurologic deterioration. MR imaging of the brain showed multiple ring-like enhancing lesions in the supra- and infra-tentorial regions, mimicking multiple metastatic brain tumors. Diffusion-weighted imaging (DWI) of the brain showed homogeneous high signals in each lesion. A cavity in the lung suggested systemic involvement of tuberculosis. Despite extensive examination, tuberculosis could not be detected. Nevertheless, anti-tuberculosis treatment was administered. The patient's neurologic condition initially deteriorated for 4 weeks, then gradually improved. MRI showed marked improvement of the lesions after anti-tuberculosis treatment. Whereas conventional MRI is not specific in such cases, DWI might be useful for early assessment of intracranial tuberculosis.

Cerebral tuberculosis mimicking intracranial tumour

Cerebral tuberculoma is a rare entity and is one of the causes of intracerebral mass lesions. A rapid diagnosis based on pathological findings improves its prognosis. We describe two cases where the tuberculoma was located in the cavernous sinus and prepontine cistern, respectively. The first case was a 36-year-old man who was admitted with progressive headache, left ptosis and diplopia. Computed tomography showed a solid enhancing mass in the left cavernous sinus. Diagnosis of meningioma was proposed and a left pterional craniotomy was performed. Histopathological examination revealed granulomatous inflammation with areas of caseation necrosis. The second case was a 20-year-old man who presented with headache, new-onset strabismus, diplopia, malaise, weight loss and low-grade fever. The lesion mimicked an aggressive meningioma on imaging. The patient was operated for primary diagnosis of cerebral tumour. The histopathological examination of the excised lesion revealed a tuberculoma. Although the incidence of tuberculosis is decreasing, a high index of suspicion must be maintained for the diagnosis of intracranial masses in the presence of risk factors for tuberculosis.

[Multiple brain tuberculomas]

A case of multiple brain tuberculosis in 32-year-old men was described. The diagnosis was made on the result of histopathological examination of excised tuberculoma. Basing on the described case, current possibilities of tuberculoma diagnostic difficulties, caused by unspecific clinical manifestation and atypical radiological lesions, was drawn.

Intracranial multiple tuberculomas: 2 unusual cases

BACKGROUND

Tuberculosis (TB) is still a major public health problem that continues to be an important cause of morbidity and mortality at worldwide level. Only 1% of patients with TB develop an intracranial tuberculoma (Tbm), usually as part of miliary TB. The radiological findings are often nonspecific, and they are difficult to diagnose without an increased index of suspicion.

CASES DESCRIPTIONS

In this report, we presented 2 unusual patients with intracranial multiple Tbms, one of whom is a 32-year-old woman who did not have pulmonary TB or other primary origin of TB. Her diagnosis was established histopathologically, and she was treated with antituberculous chemotherapy. The other patient is a 12-year-old girl who has pulmonary TB with portal hypertension together with liver cirrhosis. Her diagnosis was established with clinical, radiological, and laboratory findings, and she was treated with antituberculous chemotherapy for 18 months.

CONCLUSIONS

Intracranial Tbms have become rare in developed countries, but TB is still a very common infectious disease at worldwide level. Therefore, diagnosis should be kept in mind when confronted with brain space-occupying lesions, especially in the immunocompromised or malnutritional hosts such as liver cirrhosis. When no other active extracranial tuberculous process is found, the diagnosis should be confirmed by a biopsy before beginning antituberculous treatment, which is rapidly effective. We have not encountered in the literature such a case of multiple intracranial Tbms associated with liver cirrhosis in an adult patient.

[Tuberculoma complicating tuberculous meningitis: description of one paediatric case]

Intracranial tuberculoma is a possible complication of meningeal, miliary or pulmonary tuberculosis. In developing countries it represents 30% of space-occupying intracranial lesions, in industrialised countries only 0.1-0.2%. One recently recognised phenomenon is the development ex novo or the enlargement of the tuberculoma during antitubercular chemo-antibiotic therapy. Here we report the clinical case of an immunocompetent Italian baby girl who presented an intracranial tuberculoma during tuberculous meningitis. We underline how such an event is possible, the need for early neuroradiological evaluation and its favourable course, maintaining adequate antitubercular therapy associated with steroid therapy.

Role of diffusion weighted imaging in differentiation of intracranial tuberculoma and tuberculous abscess from cysticercus granulomas-a report of more than 100 lesions

Restricted diffusion is noted in a large number of non-stroke conditions including tuberculoma. The purpose of this study was to demonstrate spectrum of diffusion weighted imaging (DWI) abnormalities in tuberculomas and tuberculous abscess and to distinguish these from degenerating neurocysticercosis. Seventy tuberculomas and tuberculous abscesses in 30 patients were categorized in three groups depending on the intensity in the core of the lesion on T2 weighted images. Mean apparent diffusion coefficient (ADC) was calculated from the core as well as from the wall of the lesions. Forty-five lesions of neurocysticercosis in different stage of evolution in 12 patients were also included for comparison. The mean ADC value from the core of the T2 hypointense lesions was significantly higher compared to the wall ((1.24+/-0.32)x10(-3) and (1.06+/-0.15)x10(-3)mm(2)/s, respectively), while mean ADC value from the core of mildly T2 hyperintense lesions was significantly lower compared to the wall ((0.80+/-0.08)x10(-3) and (1.08+/-0.13)x10(-3)mm(2)/s, respectively). Truly T2 hyperintense lesions were divided into two subgroups, tuberculomas and tuberculous abscesses; ADC values from the core and the wall of these lesions were (0.74+/-0.13)x10(-3), (0.61+/-0.08)x10(-3) and (1.03+/-0.14)x10(-3), (1.08+/-0.14)x10(-3)mm(2)/s, respectively, and was significantly lower in core as compared to the wall. However, there was no significant difference between ADC values of the tuberculous abscess and the hyperintense tuberculomas. Vesicular and degenerating stages of cysticercus cysts from the core showed ADC values of (1.66+/-0.29)x10(-3) and (1.51+/-0.23)x10(-3)mm(2)/s, respectively, and were significantly higher than the core of all groups of tuberculomas and tuberculous abscess. We conclude that addition of DWI to routine imaging protocol may help in differentiation of tuberculous lesions from degenerating cysticercus granuloma.

Comparative evaluation of magnetization transfer contrast and fluid attenuated inversion recovery sequences in brain tuberculoma

AIM

To compare T1-weighted magnetization transfer (MT) with fluid attenuated inversion recovery (FLAIR) imaging for evaluating conspicuity and number of lesions in individuals with brain tuberculoma.

MATERIALS AND METHODS

In all 28 patients with brain tuberculoma underwent MR examination using fast spin-echo (FSE) T2, spin-echo (SE) T1, T1-weighted MT and FLAIR imaging. Post-contrast T1-weighted MT imaging was taken as the gold standard for assessing the number of lesions. Tuberculomas detected both on T1-weighted MT and FLAIR imaging were examined for the wall to be defined, and were divided into two groups on the basis of presence (group 1) or absence (group 2) of perilesional oedema visible on FLAIR imaging. The mean signal intensity of the wall of the lesions and adjacent oedema or brain parenchyma was analyzed qualitatively and quantitatively.

RESULTS

The number of lesions detected on T1-weighted MT was higher than on FLAIR imaging (209 versus 163). Conspicuity in both groups was better on T1-weighted MT images qualitatively as well as quantitatively. The difference in the signal intensity of the wall of the lesion and perilesional oedema was statistically significant only on T1-weighted MT images in group 1 (p=0.0003 versus 0.3), whereas in group 2 it was statistically significant both on T1-weighted MT and FLAIR imaging (p=0.009 versus 0.05).

CONCLUSION

FLAIR imaging is not helpful in the examination of brain tuberculomas compared with T1-weighted MT imaging, as it neither contributes to the characterization of lesion nor assesses the true disease load.

Asymptomatic pons tuberculoma in an infant with miliary tuberculosis

Miliary tuberculosis is caused by the hematogenous spread of Mycobacterium tuberculosis and consists of 1.5% of all tuberculosis cases. It is seen mostly in infants because of the immature immune system, and central nervous system CNS involvement is not rare. Tuberculomas are rarely seen in the localized form of CNS tuberculosis, and only 4% are localized in the brain stem. We report a 4.5-month-old infant who deteriorated during follow-up with the diagnosis of cytomegalovirus pneumonia, and afterwards received the diagnosis of miliary tuberculosis. Although the baby had no neurologic abnormality and cerebrospinal fluid findings were normal, cranial MRI revealed contrast enhanced nodular lesions in pons, cerebellum, and right parietal region. The case is presented to intensify the importance of CNS investigation even if the patient with miliary tuberculosis has no neurologic finding.

Imaging meningo-encephalic tuberculosis

Tuberculosis is becoming an increasingly troublesome public health problem mostly because of incomplete therapy of existing cases giving rise to multi-drug resistant strains and because of increase in immunodeficiency states from various causes. The disease affects preferentially economically underprivileged individuals. In this paper, we review the pathogenesis and radiological findings of meningo-encephalic tuberculosis. Imaging manifestations are very pleomorphic and can mimic parenchymal cerebral mass lesions or meningeal processes of different nature. Although imaging findings are generally non-specific, modern imaging plays a key role in the diagnosis. A high index of suspicion in the appropriate clinical and laboratorial setting may promote rapid diagnosis and institution of therapeutic measures that avoid death or serious neurological consequences.

Relationship between intracranial granulomas and cerebrospinal fluid levels of gamma interferon and interleukin-10 in patients with tuberculous meningitis

Cerebrospinal fluid gamma interferon (IFN-gamma) and interleukin-10 levels in 39 patients with tuberculous meningitis were serially measured. Cytokine levels did not predict intracranial granuloma (IG) development, but IFN-gamma levels in the top quartile after 1 month of therapy were highly associated (odds ratio = 18) with detection of an IG by computed tomography scanning.

Intracranial tuberculoma -- a diagnostic dilemma

The characteristics of intracranial tuberculoma on computed tomography (CT) and magnetic resonance imaging (MRI) are not well known. The authors present a patient with an intracranial tuberculoma in whom the diagnosis was confirmed only after surgical excision.

Paradoxical appearance of intracranial tuberculoma in a child with tuberculous meningitis

Intracranial tuberculomas are known to develop during treatment of tuberculous meningitis (TBM). However, they usually develop within weeks or a couple of months after the start of antituberculous therapy (ATT). We present a case of an 18-month-old boy who developed tuberculomas after 9 months of ATT, which subsequently responded to the reintroduction of steroids. Thus, one must keep a watch for neurological deterioration in a child of TBM and if it is due to tuberculomas, one may have to continue steroids and ATT for a long time.

Pseudotumor Presentation of Intracerebral Tuberculomas

Diagnosis of tuberculoma is difficult because of its tumorlike aspects. This report describes the case of a male who displayed a hemiplegia revealing an intracranial mass. Neuroimaging was consistent with a glioblastoma; however, the definite diagnosis was a tuberculoma. Clinical features of tuberculomas are nonspecific. Even though the neuroimaging features are sensitive, they are much less specific, with variability related to the tuberculoma course. Investigations leading to the diagnosis are histologic analysis showing a granuloma with or without caseating necrosis, and the microbiologic identification of Mycobacterium tuberculosis. Every intracranial tumor with malignant radiologic and clinical appearance must evoke a suspicion for tuberculoma.

Tuberculomes et méningoradiculite tuberculeuse d’évolution paradoxale sous traitement

INTRODUCTION

Neuromeningeal tuberculosis of deleterious, paradoxical, progression despite appropriate antibiotic therapy is rare.

OBSERVATION

An immunocompetent woman exhibited an immediately disseminated form of tuberculosis with progressive neurological involvement associating expanding intracranial tuberculomas and meningeal-radiculitis despite adapted anti-tuberculosis quadritherapy.

DISCUSSION

During anti-tuberculosis therapy clinical worsening is rare, particularly when 2 different manifestations are associated and the worsening occurs in an immunocompetent patient. This possibility should be systematically evoked in such cases. The explanation of this phenomenon is still unclear.

Cerebral tuberculomas in AIDS patients: a forgotten diagnosis?

The human immunodeficiency virus (HIV) infection epidemics increased the prevalence, multi-drug resistance and disseminated forms of tuberculosis. The central nervous system (CNS) tuberculosis has high mortality and morbidity, and it is usually divided into diffuse (meningitis) and localized (tuberculoma and abscess) forms. We report three cases of cerebral tuberculomas in AIDS patients: one with definitive diagnosis, confirmed with histopathology, and two with probable diagnosis, based on clinical information, radiological images, Mycobaterium tuberculosis isolation out of the CNS and adequate response to antituberculous treatment. Further, we discuss diagnostic, therapeutic and prognostic issues of tuberculomas, with emphasis in the distinction from cerebral tuberculous abscesses. Despite of their infrequent presentation, tuberculomas should be considered in the differential diagnosis of cerebral expansive lesions in patients with AIDS.

Intracranial tuberculomas and caries spine: an experience from Children's Hospital Islamabad

BACKGROUND

Pulmonary tuberculosis in infants and children in Pakistan is quite common. However, there is limited data about uncommon forms of tuberculous infection of central nervous system. Tuberculosis of nervous system is a serious disease and if not treated adequately, carries high morbidity and mortality. This study was undertaken to highlight the occurrence of relatively uncommon forms of tuberculosis in children.

METHODS

This was a retrospective review of the case records of the patients who were admitted in Children's Hospital, Islamabad with the diagnosis of cerebral tubercloma or tuberculosis of spine between January, 1994 and August, 2002. Diagnosis was based on clinical features, history of contact with tuberculous patient, abnormalities on chest X-rays and neuroimaging studies of brain and spine.

RESULTS

Nine children had cerebral tuberculomas, six more than one and in five were bilateral. Eight had caries spine, 2 cervical, 4 thoracic and 2 lumbar regions. Three had been vaccinated with Bacillus-Calemette-Guerin and family history of tuberculosis was positive in 7 (41%) children. Nine (53 %) patients had evidence of pulmonary tuberculosis on chest x-ray. Ten computed scan brain, four magnetic resonance imaging, two spinal scan and two myelographic studies were performed. Three patients with tuberculomas and five with caries recovered and 8 were left with neurological deficit. One child with cerebral tuberculomas died.

CONCLUSION

Intracranial tuberculomas and spinal tuberculosis are not rare problems in children. Early diagnosis and prompt antituberculous therapy are the most important factors for the favourable outcome.