Othello Syndrome Secondary to Cerebral Tuberculoma: A Case Report

INTRODUCTION

Othello syndrome, an eponym of Shakespeare's character, is a transnosological diagnostic term that designates a clinical picture characterised by the presence of delusions of infidelity with respect to a partner and that, consequently, can lead to typical jealousy attitudes and violent behaviour towards the partner. In its pure form, it corresponds to delusional disorder of infidelity, but it may also be secondary to brain organicity and drug use.

METHODS

Case report and non-systematic review of the relevant literature.

CASE PRESENTATION

A 26-year-old man, with a history of drug abuse and a victim of domestic violence as a child, presented with tonic-clonic seizures and intracranial hypertension three years ago, for which he underwent a craniotomy with the finding of a right frontal cerebral tuberculoma. After a lapse, he developed a clinical picture of delusions of infidelity regarding his partner and violent behaviour towards her.

LITERATURE REVIEW

Delusional jealousy is associated, like other delusions, with lesions of the right frontal lobe. Despite the high and growing prevalence of tuberculosis worldwide, there are no reported cases of Othello syndrome secondary to cerebral tuberculoma in the literature.

CONCLUSION

Othello syndrome, although not the main cause of domestic violence, can be associated with particularly violent manifestations and be secondary to cerebral tuberculoma. This is the first published case of its kind.

Central nervous system tuberculosis following delayed and initially missed lung miliary tuberculosis: a case report

Central nervous system (CNS) tuberculosis includes three clinical entities: tuberculous meningitis, intracranial tuberculoma, and spinal tuberculous arachnoiditis. All three categories are encountered frequently in regions of the world where the incidence of TB is high. Meningeal tuberculosis is a medical emergency: it is the most severe, lethal and disabling form of tuberculosis. Early diagnosis and treatment can be lifesaving. Even, in developed countries the diagnosis of tuberculous meningitis is difficult, frequently delayed or missed, and is often not microbiologically confirmed. Here I report a case of miliary tuberculosis, in a patient with diabetes mellitus and chronic kidney disease, but without HIV infection. Although the patient had regular contact with healthcare staff (hemodialysis), miliary tuberculosis diagnosis was considerably delayed. This patient, subsequently evolved into tuberculous meningitis. In spite of quadruple anti-tuberculosis treatment, corticosteroids, and general supportive care, this case resulted in death.

Isolated brainstem tuberculomas

BACKGROUND

Isolated brainstem tuberculomas are rare lesions and account for up to 5% of all intracranial tuberculomas in endemic areas. The difficulties in diagnosis and management of this condition are sparsely reported. The aim of this study is to illustrate the nuances in managing brainstem tuberculomas, define prognosis, and demonstrate a shift in management strategies with newer imaging modalities.

METHOD

A retrospective review of 14 patients diagnosed and treated with a diagnosis of 'isolated brainstem tuberculoma' between 2011 and 2015 was done. Diagnosis was made after combining the findings at clinical history, examination, as well as imaging features. Patients were treated with steroids for 6 weeks or until they made a meaningful clinical recovery, and antitubercular therapy (ATT) for a minimum of 18 months or until there was resolution of the tuberculoma. Confirmation of tubercular pathology was done by observing if response to treatment resulted in clinical improvement, which happened in all of our cases.

RESULTS

Mean age at diagnosis was 24.7 years and nine were males. Twelve patients had a combination of cranial nerve deficits with pyramidal weakness or sensory symptoms. Mean duration of symptoms was 4.7 months and tests for human immunodeficiency virus (HIV) infection were negative in all patients. Only two patients had a previous history of tubercular meningitis. Most lesions were located in the pons with size ranging from 1 to 22.2 cm³. Eight patients showed complete resolution of the lesion at latest follow-up and the rest were still on ATT. Mean duration of ATT received for resolution of the lesion was 22 months. Almost all of our patients improved clinically on steroids and ATT.

CONCLUSIONS

Intracranial tuberculomas may present with or without meningitis. A high index of suspicion is essential, especially in endemic areas. A combination of clinical symptoms, investigations, and imaging features help in coming to a diagnosis. Biopsy of a brainstem lesion is fraught with complications. Antitubercular therapy has a very good prognosis, though the duration of therapy required may be longer.

REVIEW OF THE CLINICAL, COMPUTERIZED TOMOGRAPHY SCAN AND/OR MAGNETIC RESONANCE IMAGING FINDINGS OF INTRACRANIAL TUBERCULOMA IN AN ETHIOPIAN TEACHING HOSPITAL

ACKGROUND

Ethiopia is one of the countries that has high burden of all forms of tuberculosis and there is no published report on computerized tomography scan and/or magnetic resonance imaging of intracranial tuberculomas. Objective : to review the clinical, computerized tomography and/or magnetic resonance imaging features of intracranial tuberculoma.

METHODS

retrospective review of patient’s medical records of patients operated for intracranial mass that had computerized tomography and/or magnetic resonance imaging brain scans and had histopathological diagnoses, at Tikur Anbessa Specialized Hospital between January 2009 and June 2013.

RESULTS

Of 222 operated cases of intracranial mass subjected to histopathological test 29 (14.6%) were found to have tuberculomas, 28 (14.1%) had caseous necrosis and one was a tuberculous abscess, in 25 cases imaging was available for review and were included in the study . There were 15 males and 10 females with age range being 2 to 65 years and with the Median age being 13 years. Twenty patients had computerized tomography and five patients had magnetic resonance imaging. Seizure 15/25 (60%) and headache 11/25 (44%) were the commonest presentation. Solitary or confluent large lesions were seen in 12/25 (48%) of patients. 14/25 (56%) of the lesions had their size between 2 cm and 5 cm. Majority of the lesions 15/25 (60%) were in the frontal and parietal lobes. The lesions were isodense on CT in 18/25 (72%) of the pre-contrast studies and 21/25 (84%) showed ring or rim enhancement after intravenous administration of the contrast medium.

CONCLUSION

Tuberculoma, more frequently, presented with non-specific clinical findings and chronic seizure disorder and comonly occurred in young patients and often seen infratentorialy. It is often complicated with hydrocephalus in the pediatric age group. Computerized tomography scan and/or magnetic resonance imaging features are not different from reports from other countries.

Aphasia secondary to tuberculosis: a review of a nineteenth-century case report by Booth and Curtis (1893)

The topic of aphasia secondary to tuberculosis deserves attention for two reasons: first, for better understanding rare etiologies of aphasia in medical history; and secondly, for initiating a multidisciplinary discussion relevant to aphasiologists, neurologists, pathologists, and clinicians generally. This article will focus on clinical observations of tuberculosis-related aphasia in the nineteenth century, highlighting a noteworthy case report presented by Booth and Curtis (1893).

Pituitary apoplexy syndrome as the manifestation of intracranial tuberculoma

Pituitary apoplexy syndrome is characterised by acute neuro-ophthalmological features and usually occurs due to bleeding in a pituitary adenoma. It is an unusual presentation of tuberculoma, as only few similar cases have been reported previously. A 17-year-old girl presented with headache, vomiting, altered sensorium and vision loss. MRI of the brain revealed ring enhancing sellar lesions with other enhancing lesions and leptomeningeal enhancement. Cerebrospinal fluid microscopy, biochemistry and PCR for tuberculosis confirmed tubercular meningitis. The patient was treated with antituberculous therapy and was asymptomatic at the end of treatment.

[Intracranial tuberculoma mimicking malignant tumour]

INTRODUCTION

Tuberculous involvement of the central nervous system is uncommon in western countries. Brain tuberculoma is a granulomatous inflammatory process than in rare occasions can simulate a malignant neoplasm.

CASE REPORT

A 81-year-old man regarding symptoms of several weeks of evolution of numbness affecting upper limb and right face. The neuroimaging studies showed a left parietal lesion suggestive of a primary malignant tumor. A stereotactic biopsy was performed and the pathological examination showed a brain tuberculoma. The patient was treated with anti-tuberculous drugs.

CONCLUSIONS

Parenchymal central nervous system tuberculosis are rare in our medio and may present as a space-occupying lesion with complex neuroimaging morphology suggesting a malignant neoplasm. Definitive diagnosis was performed with neuropathological studies or with the demonstration of acid-fast bacilli in the tuberculoma.

Ophthalmic manifestations of central nervous system tuberculosis--two case reports

In this report, we present two unusual ocular manifestations due to CNS tuberculosis. One of the cases is a 7 years' old boy with brain stem tuberculoma who presented with horizontal gaze palsy. The other is a 14 years' old girl with temporal lobe tuberculoma who presented with unilateral sixth nerve paresis and papilledema. Both responded well to treatment with antitubercular drugs. It highlights the importance of gaze palsy as a rare manifestation of CNS tuberculosis.

Lateral medullary syndrome due to brain stem tuberculoma

Brainstem tuberculomas are quite unusual, accounting for less than 5 % of all intracranial tuberculoma. Intracranial tuberculoma is rare form of central nervous system tuberculosis. Lateral medullary syndrome is a combination of clinical features commonly attributed to infarction in territory of posterior inferior cerebellar artery or vertebral artery. We report a case suffering from lateral medullary syndrome resulting from brainstem tuberculoma which has not been reported so far in the literature. This patient was started on antituberculous chemotherapy and repeat magnetic resonance imaging of the cranium revealed regression of the lesion.

Movement disorders identified in patients with intracranial tuberculomas

INTRODUCTION

movement disorders have been associated with deep brain lesions. This study was performed to describe the frequency and characteristics of movement disorders in patients with intracranial tuberculomas.

METHODS

patients admitted consecutively between 1989 and 2004 to the Neurology Service of Eugenio Espejo Hospital (Quito, Ecuador), with a diagnosis of intracranial tuberculomas. All patients were examined clinically, and laboratory tests and imaging studies performed. Follow-up continued up to one year after the tuberculosis treatment was completed. A nested case-control analysis was performed to compare clinical characteristics, number and location of tuberculomas, between cases with movement disorders and controls.

RESULTS

forty-nine patients with tuberculomas (31.7±20.5 years; males 53.1%) were studied. We found 16 cases (32.6%; 95%CI=19.9% - 47.5%) of movement disorders: chorea (n=7; 43.8%), tremor (n=5; 31.3%), dystonia (n=3; 18.8%) and myoclonus (n=1; 6.3%). Most cases (87.6%) developed early (10.4±5.2 days of hospitalization). On admission, patients with movement disorders showed higher severity of the illness than controls (68.7 vs. 30.3%; p=.01), along with greater motor impairment (75.0 vs. 39.4%; p=.01) and sensitivity impairment (43.8 vs. 9.1%; p=.01). The cases showed higher frequency of multiple tuberculomas (68.7 vs. 36.4%), with deep brain deep (31.3 vs. 21.2%) and more severe motor impairment (25.0 vs. 12.1%).

CONCLUSIONS

our results suggest a causal relationship between tuberculomas and movement disorders. Deep location and multiple tuberculomas may increase the risk of develop movement disorders.

Suprasellar tuberculoma presenting as panhypopituitarism

Suprasellar tuberculomas are exceptionally rare. We present the case of a middle aged male who presented with generalised apathy and meningism of two weeks duration. Neuroimaging was suggestive of tuberculomas in suprasellar cistern, while endocrinological investigation showed panhypopituitarism manifesting as pituitary hypothyroidism, hypocortisolism, and hyperprolactinemia. Cerebrospinal fluid examination showed lymphocytic reaction with raised proteins. A diagnosis of suprasellar tuberculoma with panhypopituitarism was made. The patient was started on antituberculous treatment and hormone replacement which led to remarkable improvement in condition of patient and resolution of tuberculous granuloma in follow up imaging.

Acute paraplegia in a patient with AIDS and a normal CSF examination

We report a case of tuberculous myeloradiculitis in a patient with AIDS. The case highlights the difficulty in reaching a diagnosis for the neurological symptoms of a patient with a normal CSF examination and the need for HIV screening of immune-compromised patients with myeloradiculitis.

Multiple intracranial tuberculomas associated with partial status epilepticus and refractory infantile spasms

We report the case of a 10 month-old girl presenting with multiple intracranial tuberculomas associated with partial status epilepticus and cerebrovascular accident in the left sylvian territory. She later developed paradoxical enlargement of the tuberculomas during antituberculous treatment and severe neurological sequelae with refractory infantile spasms. The development of infantile spasms in this context is particularly remarkable, and this case is illustrative of the complex interrelationship between intracranial lesions, partial status epilepticus, and infantile spasms. It also highlights the difficult diagnosis of cerebral tuberculomas in infants and further supports the need for continued vigilance in industrialized countries.

Pituitary tuberculosis mimicking idiopathic granulomatous hypophysitis

An unusual case of tubercular granulomatous hypophysitis is reported. A sellar mass diagnosed as pituitary adenoma in MRI, showed non-caseating granulomas, glandular destruction and fibrosis in histology. Stain for acid-fast bacilli (AFB) were negative and the case was misdiagnosed as Idiopathic Granulomatous hypophysitis. The patient came back 2 weeks after trans-sphenoidal endoscopic resection with meningitis. CSF showed mixed pleocytosis. PCR for Mycobacterium tuberculosis was positive. The case is reported to highlight the need to maintain a high degree of suspicion for tuberculosis in any form of granulomatous hypophysitis, with or without caseous necrosis, in regions endemic for tuberculosis to prevent subsequent complications.

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 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.

Factors affecting the outcome of neuroendoscopy in patients with tuberculous meningitis hydrocephalus: a preliminary study

BACKGROUND

In recent years, ETV has been found to be effective in patients with TBMH; however, its precise selection criteria are yet to be established. We carried out this study to identify the factors affecting the outcome of ETV in TBMH.

METHODS

Fourteen patients with TBMH (11 male patients and 3 female patients; mean age, 15.7 years; range, 9 months to 40 years) formed the study group. Various preoperative (clinical grade, ventricular morphology, basal exudates, and CNS tuberculoma) and perioperative (ependymal tubercles, third ventricular floor anatomy, exudates, and adhesions) factors were studied with regard to the result of ETV. Endoscopic third ventriculostomy could be performed on 13 patients; however, an unidentifiable third ventricular floor anatomy precluded ETV in the remaining patient. Endoscopic third ventriculostomy was assigned as "failed" if the patient needed shunt, required EVD, or died in the postoperative period. The average follow-up period for the patients was 5 months.

RESULTS

Endoscopic third ventriculostomy was successful in 9 of the 14 (64.2%) patients subjected to neuroendoscopy. Statistical analysis did not show any significant association of ventricular morphology (P = .109), basal enhancement on CT (P = .169), CNS tuberculoma (P = .169), and clinical grade (P = .057) with the result of ETV, probably because of the small number of cases. However, patients with severe hyponatremia, extra-CNS tuberculosis, an unidentifiable third ventricular floor anatomy, and adhesions in the prepontine cistern had a failed ETV. Patients with tuberculoma in the brain had a successful ETV.

CONCLUSIONS

Endoscopic third ventriculostomy is likely to fail in the presence of advanced clinical grade, extra-CNS tuberculosis, dense adhesions in prepontine cisterns, and an unidentifiable third ventricular floor anatomy. Tuberculoma in the brain in cases of TBMH may be associated with a successful ETV.

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.

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.

Endoscopic third ventriculostomy in prepontine-suprasellar tuberculoma with tuberculous meningitis hydrocephalus: a case report

We present a case of prepontine-suprasellar tuberculoma involving the premamillary region of the third ventricular floor, a site suitable to perform an endoscopic third ventriculostomy (ETV) stoma, managed endoscopically, and discuss our findings. A 5-year-old male child was admitted in an unconscious state with a history of gradually progressive symptoms of raised intracranial pressure and low-grade fever for the last 3 months. Head computed tomography showed thick enhancing basal exudates, a prepontine-suprasellar ring-enhancing lesion with consequent obstructive hydrocephalus. The child was subjected to urgent endoscopy which revealed multiple ependymal tubercles along with prepontine-suprasellar tuberculoma involving the premamillary region of the third ventricular floor. The tuberculoma was decompressed using a 5-french catheter, and ETV was performed. Postoperatively, the child improved clinicoradiologically on antitubercular chemotherapy and needed no further cerebrospinal fluid diversion surgery; he is under regular follow-up. We conclude that ETV may be attempted even in the presence of thick basal exudates and/or prepontine-suprasellar tuberculoma.

Intractable intracranial tuberculous infection responsive to thalidomide: report of four cases

Paradoxical enlargement and development of new intracranial tuberculomas and tuberculous brain abscesses on adequate antituberculosis treatment are well recognized and supposedly cytokine mediated. These lesions are often unresponsive to conventional antituberculosis treatment, corticosteroids, and surgery. We therefore assessed the effect of adjunctive thalidomide, a tumor necrosis factor alpha-modulating drug, in intractable intracranial tuberculosis that did not respond to standard medical and surgical therapy. Four consecutive children (three children with bacteriologic proof and one child with clinical evidence of intracranial tuberculosis) were studied. Three patients each had a giant tuberculous abscess, and the fourth had chronic basal arachnoiditis with progressive loss of vision. Three of the four patients had relentless neurologic deterioration, and all showed disease progression on neuroimaging despite full medical and appropriate surgical treatment. Marked clinical and neuroradiologic improvement occurred after thalidomide was added to the antituberculosis treatment regimen of these four patients. Adjunctive thalidomide might have a role in the management of intractable intracranial tuberculosis and needs further investigation in this regard.

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.

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.

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.

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.

Development of tuberculoma during therapy presenting as hemianopsia

A 6-year-old, previously healthy male presented with fever and lethargy. Tuberculous meningitis was suspected after cerebrospinal fluid examination. Antituberculous drugs were administered, and an initial computed tomographic scan of brain revealed mild ventriculomegaly only. Steroids were instituted on day 16 and gradually withdrawn 1 month later. Nine weeks after the initiation of antituberculous therapy, markedly impaired visual acuity and bitemporal hemianopsia were observed. Magnetic resonance imaging of brain revealed multiple tuberculomas, including involvement of the optic chiasm. Hydrocephalus was present. A ventriculoperitoneal shunt was inserted, and steroids were reinstituted. Visual acuity improved 9 weeks after the onset of visual acuity impairment and returned to normal 24 weeks later.Follow-up computed tomographic scan of brain 1 year later demonstrated complete resolution of tuberculomas. Development of intracranial tuberculoma during antituberculous therapy, although rare, dose not represent treatment failure, and continuation of antituberculous drugs, with or without the addition of steroids, will usually resolve the lesions.

Cavitating tuberculosis in an infant: case report and literature review

Primary cavitating tuberculosis is a rare complication of primary tuberculosis in young children. In the absence of a known adult source case, the diagnosis of tuberculosis in children can be difficult. We describe an 8-month-old baby with primary cavitating tuberculosis, in whom there was considerable delay in diagnosis, and review the literature.

Isolated "one and a half syndrome" with brainstem tuberculoma

A seldom reported causal association of two rare entities, an isolated brainstem tuberculoma and an isolated One and a half syndrome in a 12 year old girl is presented. MRI showed an isolated inflammatory granuloma in the brainstem which on empirical treatment with anti tubercular drugs resulted in complete restoration of ocular motility, along with resolution of the lesion on follow up MRI at 6 months. The diagnosis and management are discussed.

The use of thalidomide in the treatment of intracranial tuberculomas in adults: two case reports

We present two cases of tuberculous meningitis (TBM) in adults complicated by focal neurological deficits which showed progression whilst on steroids. In case 1 an MRI demonstrated multiple ring-enhancing lesions compressing the optic chiasm leading to a bitemporal hemianopia. After the introduction of thalidomide serial imaging and field perimetry at 6, 9, 12 and 24 months into treatment showed progressive improvement. In case 2, two months into anti-tuberculous treatment with steroids, the patient developed fluctuating right sided paralysis with the MRI demonstrating a large ring-enhancing mass encasing the left internal carotid and middle cerebral arteries. Thalidomide was introduced as an immunomodulatory adjunct and subsequently the patient made a complete neurological recovery. The immunomodulatory effects of thalidomide may have a role in the acute and chronic management of TBM complicated by intracranial tuberculomas.

Irreversible Blindness Due to Multiple Tuberculomas in the Suprasellar Cistern

A 14-year-old girl developed fever, severe headache, vomiting, and no light perception in both eyes over a 3-day period without a previous complaint of visual or other neurologic difficulties. Neuro-ophthalmologic examination was normal apart from meningismus and blindness. Brain imaging showed ventriculomegaly and multiple enhancing nodules around the optic chiasm. Lumbar puncture showed an elevated opening pressure with lymphocytic pleocytosis. Polymerase chain reaction and enzyme-linked immunoabsorbent antibody tests on the cerebrospinal fluid were positive for Mycobacterium tuberculosis. There was no evidence of tuberculosis elsewhere in the body. Standard antituberculous treatment, including corticosteroids, did not reverse the blindness.