Uncommon neurological presentations of tuberculoma

The neurological manifestations and autopsy findings of 3 cases of tuberculoma have been described. A cerebello-pontine angle tuberculoma presented with a long history of trigeminal neuralgia. Intramedallary tuberculoma of the spinal cord presented with transverse myelitis, history of one complete remission and a normal myelogram. A tuberculoma of the medulla led to, apart from other features, severe orthostatic hypotension. Tuberculous meningitis, as a terminal process, developed in the first two cases and the third patient died from a vasomotor collapse on suddenly standing up from bed.

Unusual cerebral tuberculoma

The unusual occurrence of a cerebral tuberculoma is herewith reported. The first manifestation of the tuberculous infection was an optic perineuritis. Treatment of the "papillitis" with steroids was followed by Jacksonian seizures--the signature of the tuberculoma. Surgical excision has produced a cure.

Surgical treatment of a mesencephalic tuberculoma. Case report

✓ A case is reported of a mesencephalic tuberculoma which was suspected clinically and removed surgically with a relatively good functional recovery.

Intracranial space-occupying masses in mental hospital patients: necropsy study

During a three year period 1970--1973 necropsies were performed on 200 patients who died in a mental hospital in the Transvaal, South Africa. There was no selection of cases other than availability of consent for postmortem examination. The necropsy rate for this period was 56%. The patients belonged to three racial groups, Black, White, and Coloured, the latter being defined as those of mixed blood. Among these 200 cases, 27 were found at necropsy to have an intracranial space-occupying mass. Mention is made of the literature dealing with the incidence and diagnosis of intracranial space-occupying masses in mental hospital patients, and the incidence of intracranial space-occupying masses in the different racial groups in South Africa.

[Cerebral tuberculosis. There clinicopathological cases (author's transl)]

The clinico-pathological report of three cases of cerebral tuberculosis, collected over a 10 year period in a single neurological department from non immigrant patients emphasizes the difficulties of diagnosis and therapy of this disease. Multiple tuberculomas have simulated either an alcoolic encephalopathy in one case or a primitive cerebral tumour in another one. In the third case, the course of an exceptional cerebral miliary tuberculosis was not modified by the treatment. Liver cirrhosis was present in every case.

Tuberculoma of the liver

During the period 1973-76 2 patients, neither immigrants, were operated on and found to have tuberculoma of the liver. Both were successfully treated. Tuberculoma of the liver is an uncommon condition and is rarely encountered as a surgical problem. It can, however, present a surgical challenge as it must be distinguished from the more common types of right upper quandrant abdominal lesions such as biliary, gastroduodenal and other hepatic diseases. The occurrence of a tuberculoma of the liver without coexistent tuberculosis elsewhere in the body is extremely rare. Its presence in association with other tuberculous foci, whilst uncommon, has been recorded on a number of occasions.

Intracranial tuberculomas and the CAT scan

Tuberculomas of the brain are rare in the United States. Although CAT (computerized axial tomography) scanning cannot distinguish these infections from other intracranial mass lesions, it provides a non-invasive technique with which to follow the course of presumptive lesions during medical therapy, and with which to search for clinically unsuspected infections. The necessity for and timing of surgery can be considered more easily with this technique. Two cases are presented with their CAT scans, including one example of the disappearance of a presumptive tuberculoma, during appropriate medical therapy.

Granuloma formation by synthetic bacterial cell wall fragment: muramyl dipeptide

A synthetic muramyl dipeptide, N-acetylmuramyl-L-alanyl-D-isoglutamine, which possesses the same structure as that of a part of the peptidoglycan monomer of wax D of tubercle bacilli or bacterial cell walls was found to induce, when injected in water-in-oil emulsion, massive granulomas often accompanying abscesses in the site of injection and draining lymph nodes of guinea pigs and rats. The granulomas were composed mainly of epithelioid cells 2 weeks after injection and were indistinguishable from those induced by tubercle bacilli. The granulomas induced in rats were less mature than those induced in guinea pigs. Allergic reaction appeared to play no important role in the development of the muarmyl dipeptide-induced granuloma.

Tuberculoma of the brain

Four patients with cerebral tuberculomas had presenting manifestations that included seizure disorder, exophthalmos, or extremity weakness. Although rare in this country, this diagnosis should not be overlooked in such patients, since combined surgical and medical therapy may be curative.

Ultrastructural basis of the vasculopathy in and around brain tuberculomas. Possible significance of altered basement membrane

The fine structure of small blood vessels in and around ten brain tuberculomas was examined. In the peripheral reactive zone of the tuberculomas, examination of 1-mu-thick survey sections established the chronic inflammatory process and the vasculitis characterized by infiltration of the vasomurium (vessel wall) by large and small mononuclear cells. This reaction was typical of chronic epithelioid cell granuloma. Electron microscopic examination of the reactive zone confirmed the vascular proliferation and vasculitis, the venule being the most frequently involved type of blood vessel. It showed the infiltrating cells to lie amidst osmiophilic, concentrically proliferated basement membrane laminae, which formed the greater part of the thickened vessel wall, generally surrounding the endothelial cells directly, the pericytes having disappeared. This appearance, together with the results of Gomori's reticulin stain on paraffin sections, suggested that the altered basement membrane material was reticulin. The possibility is discussed that the altered basement membrane material could be antigenic and that it might be responsible for perpetuating the necrotic vascular and perivascular reaction in tuberculous meningitis and tuberculomas. The above change in the basement membrane was not encountered in the blood vessels of the surrounding edematous brain. The endothelial cells and tight junctions were relatively well-preserved. Intact arterioles could be recognized even in severely edematous brain tissue. At both sites the fine structure of the blood vessels was typical of that expected in the central nervous system. Fenestrated vessels were not seen. The perivascular astrocytic end-feet were destroyed in the reactive zone and either distended or ruptured in the overtly edematous brain tissue also. In the central caseous part of the tuberculoma, there were few blood vessels, and they were in a state of advanced necrosis, but ghost outlines of proliferated basement membrane could be seen.

[The stratified tuberculoma caused by Mycobacterium kansasii with cavitation (author's transl)]

Report on a 39 years old female textile worker with an acute cavity. M. kansasii was repeatedly isolated by cultivation from the sputum. The patient became negative by treatment with INH, SM, PAS, Ethionamide, but the cavity persisted. Therefore seven months after the onset of the disease the left upper lobe was resected. A colliquative Stratified tuberculoma and some lesions of caseated bronchitis and peribronchitis were found in the neigh bourhood. Clusters and microcolonies of M. kansasii could be observed as well in the wall of the cavity as in the centre of caseated bronchial lesions. The mycobacteria had a characteristic shabe of long segmentated rods. All about the microcolonies situated in the lumina of small bronchi and bronchioli caseated lesions were present, surrounded by specific granular tissue consisting of epithelial cells, some Langhans giant cells, lymphocytes and fibrocytes. The alterations caused by M. kansasii did not differ from those lesions caused by M. tuberculosis (human.) formerly described as stratified tuberculoma and caseated bronchial lesions with mycobacteria centrally located.

[A choroidal tuberculoma simulating a melanoma (author's transl)]

The clinical picture, the angiogram, the echogram, and especially the positive P 32 test led in a 30-year-old man to the diagnosis of a choroidal melanoma. Histologic examination revealed a tuberculoma.

Solitary tuberculoma of the larynx: a case report

A case of solitary tuberculoma of the larynx in a 56-year-old man from Calabar, Nigeria, is presented. He had upper respiratory tract obstruction severe enough to necessitate a tracheostomy. It is suggested that tuberculoma of the larynx may not be as rare as a review of the currently available medical literature would suggest. More may be discovered if all cases of polypoid masses in the larynx, however innocent they look, are histologically examined.

[Bone marrow's histopathology in tuberculosis of the hematopoietic organs (author's transl)]

Through the reports of the literature, the histopathologic lesions of the bone marrow in tuberculosis of the hematopoietic organs are analysed. Whether the lesions are typical or not, it is necessary to have a bacteriologic proof of tuberculosis. Near these lesions, bone marrow's cellularity is often greater or lower, reticular fibers are often increased and sometimes reticulin fibrosis is marked. Other necrosis and granulomatous inflammation are discussed. Contribution of macrophage is described. The relationships between tuberculosis and hematologic diseases are reported.

Multiple tuberculomas of the brain. Report of a case

A case of multiple tuberculomas of the brain in a pregnant patient is reported. The symptoms and signs suggested a lesion of the cerebellum which was found to be only congested and oedematous at craniotomy. The correct diagnosis was made at autopsy.

[Complete atrio-ventricular block caused by tuberculoma of the inter-atrial septum. Histological analysis]

A syndrome of obstacle to the outflow of the left ventricle was found in a woman with atrio-ventricular block with narrow ventricular complexes. A tuberculoma of the intar-atrial septum was responsible both for the obstacle to left ventricular ejection and for the block which was found to be proximal on microscopic examination.

Acid mucopolysaccharide metabolism in leprosy. 1. Storage of hyaluronic acid and its possible significance in the pathogenesis of leprosy

A histochemical analysis of 102 skin biopsies from a variety of leprosy types revealed the persistent presence of hyaluronic acid in lepra cells of lepromas. In contrast, the hyaluronic acid content of tuberculoid epithelioid cells showed a minimum amount of hyaluronic acid and hyaluronic acid tended to disappear from these granulomas as they aged. The macrophages of dimorphous leprosy occupied an intermediate position with respect to hyaluronic acid content and distribution, resembling the tuberculoid in BT cases and the lepromatous expression in BL cases. It is suggested that hyaluronic acid, in a manner similar to M. leprae and lipid, has a quantitatively varied distribution reflecting the immunopathologic spectrum of leprosy. This finding suggests that acid mucopolysaccharide may be significantly involved in that host/parasite interaction in leprosy.

Tuberculoma of the brain stem: control of relapses by steroid therapy. Case report

✓ A tuberculoma is reported, with an acute onset and a recurring course of remissions. The successful use of steroid therapy is discussed.

[Intracraniel tuberculoma. Report of 2 cases]

Os tuberculomas intracranianos são de difícil diagnóstico pré-operatório e, atualmente, constituem raridade em alguns países. Os autores relatam dois casos, com extirpação total do processo, em que o diagnóstico foi feito após intervenção cirúrgica. São comentados vários aspectos referentes ao diagnóstico e a conduta terapêutica nos tuberculomas intracranianos.

Extraosseous extradural tuberculous granuloma simulating a herniated lumbar disc. Case report

✓ A 25-year-old man with left-sided sciatica, in whom the cerebrospinal fluid and x-ray films of the spine were normal, was diagnosed as having a L5-S1 disc prolapse. At surgery extradural, extraosseous granulation tissue was removed, which histologically proved to be a tuberculous granuloma.

Tuberculoma of the orbit and lacrimal gland

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