Experiences and conceptualisation of spinal intramedullary tuberculoma management

Intramedullary Conus Medullaris Tuberculoma: A Case Report and Review of the Literature

Intramedullary tuberculoma (IMT) of the conus medullaris is extremely rare. We present a case of intramedullary conus medullaris tuberculoma in which the diagnosis was based on there being very high levels of adenosine deaminase (ADA) in the patient’s cerebrospinal fluid (CSF) and improvement with antituberculous therapy. A 78-year-old man presented after having had a dull ache in both thighs and progressive paraparesis. The patient’s medical history included diffuse large B-cell lymphoma, which had undergone remission due to chemotherapy two years earlier, and long-term, well-controlled diabetes. A chest X-ray showed no evidence of tuberculosis. The results of CSF analysis were compatible with Froin’s syndrome. An initial diagnosis was made of an intramedullary tumor of the conus medullaris, based on magnetic resonance imaging (MRI). A myelotomy and multiple punch out biopsy were performed, and histopathology of the tissues revealed mild reactive gliosis. Due to the patient having high levels of CSF-ADA, IMT of the conus medullaris was suspected. The patient was treated with an 18-month course of antituberculous therapy. The dull ache gradually disappeared, and motor power improved slightly. A follow-up MRI of the lumbosacral (LS) spine revealed that the lesion had completely disappeared. Intramedullary tuberculoma of the conus medullaris should be considered in patients with underlying malignancy and no symptoms of systemic tuberculosis. CSF adenosine deaminase levels can be helpful in determining the presence of central nervous system tuberculosis when other systemic signs of disease are lacking.

Tuberculoma of spine mimicking intramedullary tumour: A case report

•

Spinal intramedullary tuberculoma is a rare case.

•

Clinical presentation of spinal IMTB is non-distinctive from other intramedullary lesions in the absence of systemic TB.

•

Tuberculoma should be considered in the differential diagnosis of all intramedullary space-occupying lesion (SOL) in TB endemic countries.

•

Early surgical decompression in selected cases may provide good long-term outcomes.

Introduction

Spinal intramedullary tuberculoma (IMTB) is a rare disease that accounts for 1 to 2/100,000 patients with tuberculosis [1]. This case demonstrated that this patient had atypical presentations compared to common tuberculosis considering that IMTB cases are really rare.

Case presentation

A 19-year-old male presenting with back pain and weakness of both lower limbs, which started in the left lower limb and subsequently involved the right lower limb for three months. He had sensory impairment below T6 and hypoesthesia. He complained of urine hesitancy and a feeling of incomplete voiding of urine. He was on anti-tubercular treatment (ATT) for last two months. MRI exhibited hypointense portion on T1-weighted images. T2-weighted image also showed hypointensity at T6, which suggested for intramedullary mass. Excisional biopsy was suggestive for tuberculoma.

Discussion

In TB-endemic country like in Indonesia, tuberculoma should be considered as a differential diagnosis for intramedullary SOL irrespective of age or presence of extra-cranial focus of TB. MRI is the optimal tool for evaluating and diagnosing IMTB at an early stage and useful in follow-up. However, IMTB imaging characteristics may vary with immune response of individual or the stage of the tuberculoma formation [3]. The aim of early surgery is to decompress the spinal cord and achieve improvement in neurological function.

Conclusion

This case was reported to emphasize that early surgical decompression is required as a delay might cause damage to the spinal cord. This case also provides some evidences based data, thus contributing to the future research studies and clinical practice.

A rare case of disseminated tuberculosis; multiple intracranial and intramedullary tuberculomas with concurrent tuberculous spondylitis and meningitis

Concomitant presentation of intracranial and intramedullary tuberculomas is a rare entity. We report a 38-year-old immunocompetent woman with intramedullary and intracranial tuberculomas with concurrent tuberculous spondylitis and meningitis, who presented with paraparesis and back pain. Despite initial antituberculous therapy, the patient’s neurologic status deteriorated with the development of paraplegia. Following surgical intervention, the patient gradually recovered muscle strength and bladder function.

Diagnosis and Management of Intraspinal Tuberculoma with Giant Paraspinal Abscesses

BACKGROUND

Although tuberculosis is rare in the west, in recent years, it's becoming more and more common in China. Intraspinal tuberculoma is extremely rare, but it's an important cause of morbidity. Magnetic resonance imaging scanning is an effective method for the diagnosis of intraspinal tuberculoma.

CASE DESCRIPTION

This case report shows an intraspinal tuberculoma with giant paraspinal abscesses in a 28-year-old female patient with subacute progressing neurologic deficit. L1-L5 laminectomy was performed, followed by extensively excision of intraspinal and paraspinal lesion. Antituberculous treatment was carried out after pathologic diagnosis. An excellent clinical outcome was obtained. Within 24 hours of the surgical procedure, muscle weakness in both lower extremities started to improve. Three days later, the patient felt muscle strength recovered significantly, with grade 4/5 in the lower limbs in 2 weeks. Six weeks later, the patient was able to walk without assistance.

CONCLUSIONS

The case was treated by surgical excision of an intraspinal and a paraspinal lesion followed by normal quadruple antituberculous therapy. Although intraspinal tuberculoma is a rare entity, it can be effectively diagnosed on the basis of magnetic resonance imaging scanning and treated by the combination of medical and surgical treatments.

Medullar Kock without Pott: 13 cases observed at the university hospital center of Conakry, Guinea

Background: The diagnostic certainty of medullar tuberculosis (TB) without Pott disease is difficult to establish in a tropical environment with the large group of infectious, parasitic, and systemic myelopathies, despite the increasing availability of magnetic resonance imaging (MRI) data and improvement of biological exploration platforms. Methods: We retrospectively analyzed the files of 186 patients hospitalized in the Department of Neurology and Neurosurgery of the University Hospital Center of Conakry, Guinea, between 2008 and 2016 for the management of non-compressive and compressive myelopathy. Biological evidence of TB infection was demonstrated for 13 (6.9%) patients. Results: Infectious clinical picture prior to the development of neurological signs was reported in 11 patients (84.6%). The neurological signs were summed up by the existence of a sensitivo-motor semiology of progressive evolution (100% of cases) with sphincter disorders in 11 patients (84.6%) and a medullary compression symptomatology with a lesion and under lesion syndrome from the outset in 4 patients (30.8%). Medullary MRI revealed an extensive intramedullary hypersignal in 9 patients with non-compressive myelopathy and in 4 cases, the lesions appeared in T1 hypersignal and T2 isosignal were localized. Lumbar puncture (LP) revealed lymphocytic pleocytosis, hypoglucorrhage (0.3 to 0.5 g/l), and leukocytosis. Conclusion: This study reveals a classic clinical, biological, neuroradiological, and evolutionary profile of compressive and non-compressive myelopathies. These results are important for the therapeutic and evolutionary discussion of TB myelopathies for good management.

Spinal intramedullary tuberculoma following pulmonary tuberculosis: A case report and literature review

RATIONALE

Spinal intramedullary tuberculoma (IMTB) is a rare disease that accounts for 1 to 2/100,000 patients with tuberculosis. We presented a case with pulmonary tuberculosis and concurrent IMTB at C3 to C5 level and reviewed the recent case series and discussed the diagnosis, treatment, and outcome.

PATIENT CONCERNS

A 33-year-old male had concurrent pulmonary TB and IMTB at the C3 to C5 level. He had quadriplegia (muscle power 0 at 4 limbs) and sensory loss below C5 level. He also had incontinence, anal tone loss, and paradoxical respiratory pattern.

DIAGNOSIS

Spinal magnetic resonance imaging (MRI) showed a 25 11mm intramedullary lesion at C3/C4 level. Under the impression of IMTB, he underwent surgery.

INTERVENTION

We performed C3 to C5 laminectomy and en bloc removal of the tumor. The patient kept receiving anti-TB medications after the surgery.

OUTCOME

His 4 limbs muscle power had improved but could not be liberated from the endotracheal tube, so tracheostomy was performed. Muscle power gradually increased to 3 points in his upper limbs and to 2 points in his lower limbs. Sensation in his 4 limbs gradually improved as well.

LESSONS

IMTB is a rare disease that should be treated with a combination of medication and surgery. For patients with prominent spinal cord compression and neurological symptoms, early operation to remove the tumor is necessary.

Spinal Intramedullary Tuberculosis with Concurrent Supra- and Infratentorial Intracranial Disease in a 9-Month-Old Boy: Case Report and Comprehensive Review of the Literature

BACKGROUND

Tuberculous involvement of the spinal cord parenchyma is an exceedingly rare clinical entity; even more so is concurrent intracranial tuberculosis (TB). Spinal intramedullary TB presents with a characteristic subacute myelopathy, with slowly progressive paraplegia, sensory deficits, and/or bowel and bladder dysfunction. Diagnosis is strongly suspected with a clinical history of known TB in conjunction with characteristic findings on magnetic resonance imaging. Management involves multiagent antitubercular chemotherapy without or with operative intervention.

CASE DESCRIPTION

We present a case of a 9-month-old boy with a retrospectively recognized history of pulmonary TB presenting with fever and back tenderness found to have lower-extremity hypertonia and clonus. Imaging revealed concurrent intracranial and spinal intramedullary tuberculomas. The patient was treated for hydrocephalus with external ventricular drainage followed by T8-T10 laminectomy, drainage of abscess, and duraplasty. Parietal lobe biopsies proved the tuberculous etiology of intracranial lesions.

CONCLUSION

Etiopathogenesis, diagnosis, and management considerations of spinal intramedullary tuberculosis are reviewed and discussed.