Brainstem tuberculoma: A delayed IRIS

We describe a twenty six years old lady with tuberculous meningitis who developed new onset left ptosis and binocular diplopia with features of left fascicular 3rd nerve palsy after 9 months of anti tubercular therapy (ATT) and imaging revealed new onset tuberculoma in the mid-brain. Tuberculoma responded to steroids while continuing ATT. Formation of new tuberculoma as a part of immune reconstitution inflammatory syndrome (IRIS) is possible even after prolonged therapy of 9 months, which responded well to only steroids without altering ATT.

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.

Choroid plexus tuberculoma. Diagnosis, management and role of endoscopy

Ventricular involvement in central nervous system tuberculosis can be in the form of tuberculous ependymitis, intraventricular tuberculoma, intraventricular tuberculous abscess, choroid plexitis and choroid plexus tuberculoma. Only a few cases of choroid plexus tuberculomas have been described and even more rare is the description of the role of endoscopy in management of intraventricular tuberculomas. We report a 33-year-old patient while on treatment for tubercular meningitis who developed a left side choroid plexus lesion with loculated temporal horn. To confirm the diagnosis, endoscopic biopsy of the lesion was carried out. The final histopathology was tuberculoma. Intraventricular tuberculomas are usually associated with recalcitrant lesions, probably due to the poor drug levels within the CSF or as an indirect effect of immune resistance and biopsy becomes important to rule out other possibilities.

[A clinical report of five cases of central nervous system miliary tuberculomas first diagnosed by neurologists]

To explore the clinical characteristics and imaging features of miliary tuberculomas in central nervous system(CNS). A total of 5 cases diagnosed with tuberculosis in CNS first diagnosed by neurologists in Navy General Hospital of PLA were enrolled in the study. All clinical and imaging data were collected and analyzed retrospectively. The main initial symptoms were fever and headache (4/5). Multiple diffused miliary lesions were shown by brain MRI, with maximum diameter ranged from 1-4 mm and ring-shape or nodular enhancement after gadolinium injection. As mycobacterium tuberculosis could seldomly be found in serum and cerebrospinal fluid, contrast MRI remains the effective method for detecting miliary tuberculomas in CNS.

Analysis of 30 patients with acupuncture-induced primary inoculation tuberculosis

Primary inoculation tuberculosis is a skin condition that develops at the site of inoculation of Mycobacterium tuberculosis in tuberculosis-free individuals. This report describes the diagnosis, treatment and >1 year follow-up of 30 patients presenting with acupuncture-induced primary inoculation tuberculosis. Our data provide a deeper insight into this rare route of infection of tuberculosis. We also review effective treatment options.

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.

A case of cerebral tuberculosis after liver transplant and literature review

The risk of active tuberculosis is high in solid-organ recipients. We evaluated the clinical presentation of tuberculosis. Pulmonary locations were the most frequent, and extrapulmonary locations were rarely seen. Among extrapulmonary sites, intracranial tuberculosis is rare, with a few case reports reported in the literature. We report a case of 27-year-old man, who received deceased-donor liver transplant due to hepatitis B virus-related chronic liver failure. One month after the liver transplant, neurologic symptoms developed, then he had attacks of tonic-clonic convulsions. Cerebral stereotactic needle biopsy of left temporal lobe was performed. Histopathologically gliosis, rare lymphocyte infiltration, and epithelioid histiocytes were seen. Histochemical staining by Ziehl-Neelsen stain noted acid-fast resistant bacillus. The case was diagnosed as granulomatous inflammation which led to tuberculosis. In addition to antituberculosis therapy, he was given antiviral therapy for prophylaxis. During therapy, reactivation of hepatitis B virus was noted, and the recurrent diseases of hepatitis B virus-related viral hepatitis was diagnosed on serial biopsies. Ten months after transplant, he died from liver failure. Tuberculosis is a serious opportunistic infection in transplant recipients. The incidence of Mycobacterium tuberculosis infection in organ transplant recipients worldwide ranges from 0.35% to 15%. In nonrenal transplant, rejection within 6 months before the onset of tuberculosis and type of primary immunosuppressive regimen were predictors of tuberculosis infection occurring 12 months after transplant. The diagnosis and effective management of tuberculosis after transplant warnings recognition of the epidemiologic and clinical characteristics of tuberculosis in transplant recipients.

Isolated thalamic tuberculoma presenting as ataxic hemiparesis

Lacunar syndrome is a neurodeficit secondary to a deep cerebral lesion, usually because of microatheroma of small arteries. Ataxic hemiparesis (AH) is a lacunar syndrome with unilateral pyramidal weakness and ipsilateral ataxia. Thalamic tuberculoma, as a cause of AH, has not been previously described in the literature. We describe an elderly man who presented with left hemiparesis and ipsilateral ataxia. Clinical examination revealed upper motor neuron left facial paresis and left-sided hemiparesis. The patient had incoordination in left upper and lower limbs. Mantoux test was positive and erythrocyte sedimentation rate was elevated. MRI of brain showed a conglomerated hypointense lesion in the right thalamus with a peripheral hyperintensity on T1-weighted imaging and a hyperintense lesion in T2-weighted imaging with significant perilesional oedema, suggesting a tuberculoma. The patient was treated with antitubercular therapy and was symptomatically better at the 9 months follow-up.

Tuberculoma of the central nervous system--a case report

Tuberculoma of the brain is a rare form of central nervous system (CNS) tuberculosis with non-specific clinical manifestation. Due to its similarity with many other infectious and non-infectious lesions, diagnosis is difficult. The study presents the case of a patient who developed CNS tuberculoma during the course of tuberculous meningitis.

[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.

Cerebral tuberculoma presented as primary malignant brain tumor: a case report

A 62 year-old Thai man presented symptoms of chronic progressive headache for nearly one year and left side ataxia for two weeks. MRI brain suggested a primary malignant brain tumor with moderate hydrocephalus. Total removal of the lesion was performed. The histopathological report was caseating granulomatous inflammation involving cerebellar parenchyma; suggestive of tuberculoma, PCR for M. Tuberculosis complex, using brain tissue from formalin-fixed paraffin-embeded block, yields positive result for M. Tuberculosis complex. He was treated with antituberculous drugs.

Short duration respiratory illness with abducens palsy in a young man

Acute onset of diplopia associated with high-grade fever, sore throat and cough without features of raised intracranial tension in a young patient is an uncommon presentation. A diagnosis of abducent nerve palsy due to pontine tuberculoma associated with miliary tuberculosis was made based on sputum examination, chest x-ray and MRI. On diagnosis, monocular patching of the left eye was performed to avoid diplopia and primary antitubercular drugs with systemic steroids were given. An unfortunate 48 h delay in starting the antitubercular treatment likely decreased the probability of survival.

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.

Brain tuberculoma (Mycobacterium africanum): high index of suspicion helps in avoiding biopsy/surgery

Partial seizures can be due to a growing cerebral lesion, which may be tumoral or inflammatory/infectious in nature. The differential diagnosis is obviously important; increasing immigration to Europe from Africa is leading to an increase of infectious disease involving also the central nervous system. The authors report imaging the a case of a brain tuberculoma due to Mycobacterium africanum mimicking brain tumor, in which diagnosis was possible by inoculum in guinea-pig of material obtained by mediastinal biopsy of enlarged lymph nodes. Specific treatment led to marked reduction in the size of the brain lesion.

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.

Manifestations of cerebral tuberculosis

Intracranial tuberculosis continues to be a serious problem in both the developing and developed world, with significant morbidity and mortality. It has protean manifestations and at times, poses significant diagnostic challenges to both the radiologist and the treating physician. This pictorial essay aims to acquaint the radiologist with the varied imaging spectrum of intracranial tuberculosis, both the common and uncommon appearances.

Intracranial tuberculomas in patients with tuberculous meningitis: predictors and prognostic significance

SETTING

Intracranial tuberculomas are commonly observed neuroimaging abnormalities in tuberculous meningitis (TBM).

OBJECTIVE

to evaluate the predictors and prognostic significance of tuberculomas in patients with TBM.

DESIGN

In a retrospective follow-up study, contrast-enhanced magnetic resonance imaging was performed at study inclusion and after 9 months of follow-up. Univariate analysis and multivariate analysis were used to identify predictive factors for tuberculoma. Prognosis (death and severe disability) was assessed using the modified Rankin scale.

RESULTS

At inclusion, 43 of 110 patients had cerebral tuberculomas. Seven patients developed paradoxical tuberculomas. Predictors of tuberculomas were raised cerebrospinal fluid (CSF) protein (>3 g/l) and meningeal enhancement. Multivariate analysis did not show any significant predictors. During follow-up, the only significant predictor of paradoxical development of tuberculomas was raised CSF protein (>3 g/l). After 9 months of follow-up, 32 patients had died or had severe disability. Survival analysis revealed that patients with tuberculomas and those without tuberculomas had a similar prognosis.

CONCLUSION

Tuberculomas occurred in approximately 39% of the patients with TBM. Significant predictors were meningeal enhancement and raised CSF protein. TBM patients with or without tuberculomas had a similar prognosis.

Disseminated intracranial tuberculoma mimicking neurocysticercosis

Intracranial tuberculoma and neurocysticercosis (NCC) are the most frequent granulomatous infections in the central nervous system. Here we report a 41-year-old man with disseminated intracranial tuberculoma mimicking NCC. The patient complained of relapsing vertigo and vomiting consistent with Bruns syndrome. Serum antibodies against cysticercosis were positive. Magnetic resonance imaging (MRI) of the brain showed multiple disseminated ring-enhanced lesions. An initial diagnosis of NCC was made based on clinical signs and MRI. However, during antiparasitic treatment, the patient exhibited fever, meningitis signs, and positive cerebrospinal fluid findings for tuberculosis. The diagnosis was therefore corrected as tuberculoma. After three months of antituberculous treatment, the patient recovered clinically and on MRI. Our results highlight the importance of differential diagnosis of these two diseases in the early stage.

[Tuberculoma of the posterior fossa: 3 cases in the departement of neurosurgery, university hospital of Gabriel Toure]

The cerebral tuberculoma is an expansive process of slow evolution of the tuberculous bacillus. Bacteriological diagnosis is rarely made. It is usually radiological or histological. The treatment is medical and surgical. We conducted a retrospective study from March 2007 to February 2010 which focused on three cases of cerebral tuberculoma. Two of our patients were male, 75% against 25% female: The age of our three patients was respectively 47, 23, and 4 years. The history of extrapulmonary tuberculosis was found in one case. The heaviness of the head was the pattern in a patient operated on for Pott's disease. The diagnosis was suspected by neuroradiology in 3 patients and histological confirmation was made in 2 cases. The polychimiotherapy of 12 months was established and the improvement has been obtained from the third month of treatment.

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.

Multiple intracranial tubercular abscesses in a child

2 Year old girl presented with fever and cough for 4 months. Neurological examination revealed right sided hemiplegia. Contrast enhanced computed tomography of brain showed multiple hypodense ring enhancing lesions. Pus on aspiration of intracranial abscess showed positive polymerase chain reaction for Mycobacterium tuberculosis. A possibility of tuberculosis though not commonly recognised may be considered in any child presenting with prolonged fever and multiple intracranial abscesses.

[Athetosis in relation with intracranial tuberculomas in a patient from Burkina Faso]

Athetosis is generally characterized by involuntary movements due to damage of the extrapyramidal tract secondary to neonatal cerebral anoxia or nuclear icterus. The purpose of this report is to describe the case of a 41-year-old man who was admitted to the neurology department of the Ouagadougou teaching hospital in Burkina Faso for right hemiathetosis in relation with intracranial tuberculomas ongoing for two years. Diagnosis was based on clinical findings, i.e., lymph node tuberculosis and positive HIV1 serology; on CT scans showing multiple low density nodular lesions of variable size with annular contrast at the level of the right cerebellum and calcification at the left parietal level and in projection of the left capsulolenticular area; and on favorable response to tuberculosis treatment.

British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children

SUMMARY AND KEY RECOMMENDATIONS: The aim of these guidelines is to describe a practical but evidence-based approach to the diagnosis and treatment of central nervous system tuberculosis in children and adults. We have presented guidance on tuberculous meningitis (TBM), intra-cerebral tuberculoma without meningitis, and tuberculosis affecting the spinal cord. Our key recommendations are as follows: 1. TBM is a medical emergency. Treatment delay is strongly associated with death and empirical anti-tuberculosis therapy should be started promptly in all patients in whom the diagnosis of TBM is suspected. Do not wait for microbiological or molecular diagnostic confirmation. 2. The diagnosis of TBM is best made with lumbar puncture and examination of the cerebrospinal fluid (CSF). Suspect TBM if there is a CSF leucocytosis (predominantly lymphocytes), the CSF protein is raised, and the CSF:plasma glucose is <50%. The diagnostic yield of CSF microscopy and culture for Mycobacterium tuberculosis increases with the volume of CSF submitted; repeat the lumbar puncture if the diagnosis remains uncertain. 3. Imaging is essential for the diagnosis of cerebral tuberculoma and tuberculosis involving the spinal cord, although the radiological appearances do not confirm the diagnosis. A tissue diagnosis (by histopathology and mycobacterial culture) should be attempted whenever possible, either by biopsy of the lesion itself, or through diagnostic sampling from extra-neural sites of disease e.g. lung, gastric fluid, lymph nodes, liver, bone marrow. 4. Treatment for all forms of CNS tuberculosis should consist of 4 drugs (isoniazid, rifampicin, pyrazinamide, ethambutol) for 2 months followed by 2 drugs (isoniazid, rifampicin) for at least 10 months. Adjunctive corticosteroids (either dexamethasone or prednisolone) should be given to all patients with TBM, regardless of disease severity. 5. Children with CNS tuberculosis should ideally be managed by a paediatrician with familiarity and expertise in paediatric tuberculosis or otherwise with input from a paediatric infectious diseases unit. The Children's HIV Association of UK and Ireland (CHIVA) provide further guidance on the management of HIV-infected children (www.chiva.org.uk). 6. All patients with suspected or proven tuberculosis should be offered testing for HIV infection. The principles of CNS tuberculosis diagnosis and treatment are the same for HIV infected and uninfected individuals, although HIV infection broadens the differential diagnosis and anti-retroviral treatment complicates management. Tuberculosis in HIV infected patients should be managed either within specialist units by physicians with expertise in both HIV and tuberculosis, or in a combined approach between HIV and tuberculosis experts. The co-administration of anti-retroviral and anti-tuberculosis drugs should follow guidance issued by the British HIV association (www.bhiva.org).

[Intracranial tuberculoma: a case report and review of the literature]

INTRODUCTION

Cerebral tuberculoma constitutes an important neurotuberculosis clinical form with high morbimortality and important diagnoses difficulty.

CASE REPORT

Only giant cerebral tuberculoma case in 3 years-old man who present dizziness and surgically treated by diagnostic suspicion of cerebral tumor.

CONCLUSION

Cerebral tuberculomas can often be confused with cerebral tumors when they are not included in differential diagnosis.

[Neurotuberculosis: a continuing clinical challenge]

In Germany neurotuberculosis is quite rare. Familiarity with the disease is nonetheless important because of many differential diagnoses and therapeutic implications. The diagnosis of neurotuberculosis is made by considering of clinical presentation, CSF, and cerebral imaging. Early diagnosis, prompt initiation of effective antitubercular therapy, and clinical staging are necessary for establishing a long-term treatment prognosis. The results of neurotuberculosis therapy are often unsatisfactory despite the availability of effective drugs. Lasting damage or death can be averted in fewer than half of the patients. Studies now confirm that early adjuvant corticoid therapy reduces lethality and morbidity. Resistant new strains of the pathogen, Mycobacterium tuberculosis, complicate therapy. Recent discoveries especially in diagnosis and therapy are explained using case evidence.

[Cerebelous syndrome by infratentorial brain tuberculornas and mutisystemic tuberculosis in AIDS patient]

We present a clinical case of a patient who consulted for a cerebelous syndrome and diplopia associated to 10 kg weight loss in six months and multiple adenopathies. Cerebral imagenology study evidenced the presence of granulamatous masses at the cerebellum and midbrain level, there were no cerebrospinal fluid abnormalities. Systemic tuberculosis (TB) diagnosis was done based in finding of acid-fast bacilli positive staining in urine and lymph node biopsy. HIV infection was documented by ELISA serology. CD4 cell count was 590 cell/mm3, classifying the case a AIDS Cl stage. TB was treated according to national guidelines leading to good clinical and imagenology evolution. The clinical case scenario of infratentorial tuberculomas without meningitis as a first manifestation of TB and AIDS is unusual, generating our interest in reporting this case.

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.

NMR spectroscopic identification of cholesterol esters, plasmalogen and phenolic glycolipids as fingerprint markers of human intracranial tuberculomas

Detailed (1)H and (13)C NMR spectroscopy of lipid extracts from 12 human intracranial tuberculomas and two control brain tissue samples was performed to assess the role of lipids in the disease process. One-dimensional and two-dimensional NMR techniques were used to resolve the mixture of lipid components and make resonance assignments. The lipid components that could be identified in tuberculoma lipid extracts and not in control samples were: cholesterol ester, plasmalogen and phenolic glycolipids. It is proposed that the combined occurrence of these lipid components can be used as 'fingerprint markers' for the differentiation of intracranial tuberculoma from healthy brain tissue. Furthermore, phenolic glycolipids present in intracranial tuberculomas may have diagnostic significance in differentiating them from other disease conditions of the central nervous system such as malignant tumors.

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.