Bombay Hospital Journal, Vol. 54, No. 2, 2012

Introduction

r i n g e n h a n c i n g l e s i o n o n Aradioimaging is always a matter of

confusion between neurocysticercosis and

tuberculoma especially in Indian

population where both the things are

common. Usually if lesions are multiple

w i t h c a l c i f i c a t i o n t h e y a r e

neurocysticercosis, however it is usually

crosschecked on the basis of history,

c l in ical f indings and other lab

investigations and the diagnosis is always

based on cumulative results.

Case Report

A 28 year old on mixed diet came with complains of

1. low grade on and off fever since 4 months

2. Inability to move both the eyes on right side

since 10 days

3. Deviation of mouth to the left since 10 days

4. Dull aching generalised headache since 10 days.

There is no history of significant weight loss or

loss of appetite

There is no past history or family history of

tuberculosis.

On examination

Patient was absolutely conscious and oriented

with normal vitals.

No lymphadenopathy or soft tissue palpable

mass s/o soft tissue cystecerci.

Fundoscopy was not suggestive of papiloedema

A Case of Multiple Brain Parenchymal Tuberculoma

Anannya A Mukherji*, Alok A Shah**, Santwana D Chandrakar***

*Professor and Unit Head, **Junior Resident, ***Associate Professor, Department of Medicine. Dr. D. Y. Patil Medical College. Nerul

Abstract

We report a case of 28 year old male with relatively clinically silent multiple ring

enhancing lesion which was diagnosed as multiple brain parenchymal tuberculoma

and treated on the same line.

or ocular cysticerci.

Chest was absolutely clear.

On CNS findings were suggestive of right sided

lower motor neuron type of facial palsy and right

sided gaze palsy with horizontal nystagmus.

Investigations

Hb-15 gm/dl

Total count -12000/ul with neutrophilia

Eosinophil-2%

Fasting ESR -70 mm at end of one hour

Elisa for HIV was negative

Anticysticercal antibody turned negative

Stool routine and microscopy was not suggestive of

ova/cyst

Chest X-ray normal

All X-ray of soft tissue not suggestive of soft

tissue calcifications.

MRI was suggestive of multiple brain

parenchymal tuberculoma as in the photograph.

Fig. 1 : MRI images prior to treatment

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Bombay Hospital Journal, Vol. 54, No. 2, 2012

Fig. 2 : MRI images after the treatment

of repeat admission

Patient was started with

Injectable mannitol, injectable dexamethasone,

four drugs anti tubercular therapy which included

rifampicin, isoniazid, ethambutol, pyrazinamide and

pyridoxine. Phenytoin, folic acid was also started in

view of the multiple numbers of lesions as

prophylactic anti epileptic. He was hospitalised for 5

days and discharged with oral steroids with tapering

schedule, ATT, antiepileptic, folic acid and

pyridoxine. Subsequently after one month patient

developed paradoxical symptoms of raised

intracranial tension, with headache and vomiting,

though the repeat MRI showed improvement in the

lesions Patient ultimately finished full course

ATT and no admissions required then.

Discussion

The incidence of intracranial

tuberculomas varies from country to

country, ranging between 0.5% and 30.5%

of all brain tumours, and those involving 1the brain stem ranges from (0 to 4.3%).

Though mult ip le intracrania l

tuberculomas are seen in autopsy

findings, they are comparatively rarely

seen clinically. The highlight of this case is

that the despite the brain being studded

with multiple tuberculomas, the patient

was comparatively asymptomatic and had

features of only brain stem involvement in

the form of a horizontal gaze palsy and a

mild lower motor neuron facial palsy.

T u b e r c u l o m a i s a p e c u l i a r

manifestation of tuberculosis which

occurs in any solid organ of the body. It is

usually formed by conglomeration of

several miliary tubercles, which form

around the outer sheaths of the small

cerebral blood vessels. The centre of the

conglomeration becomes caseous.

Caseous material gets inspissated and

sometimes liquefied. A thick capsule may 1form around these lesions.

Intracranial tuberculomas occur most

commonly in the cerebral and the

cerebellar hemispheres, which have

relatively profuse blood supplies.

Presence of gaze palsy, as the only

manifestation is relatively rare in the

English literature. Tuberculoma is

characterised by its clinical heterogeneity,

which particularly depends on the variable

location, size and number of the

tuberculomas. Lisa and Deangelis

emphasise the high frequency of seizures

(50%-80%), but intracranial hypertension 2or neurologic deficit can also be seen.

Unlike malignant tumours of the

central nervous system, tuberculomas

often grow without permanently

destroying the surrounding neural tissue,

thus enabling good clinical recovery.

However, tuberculomas may rupture into

the subarachnoid space, causing

meningitis, vasculitis, diffuse cerebral 3oedema, and hydrocephalus.

Usually brainstem tuberculoma

presents with low grade fever, weight loss,

vomiting, sixth and seventh cranial nerve

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Bombay Hospital Journal, Vol. 54, No. 2, 2012

affection along with motor and sensory

symptoms which are usually unilateral.

Isolated cranial nerve palsies are often

attributed to lesions of the respective

nerves along their extra axial courses.

However, ischaemic or haemorrhagic

lesions of the brainstem also cause

isolated cranial nerve palsies through

involvement of the intra axial segments of 4the respective nerves.

Diagnosis is usually confirmed by CT

scan brain (plain and contrast) and by

MRI. In a study done by Wasey et al , who

studied more than 100 cases of

tuberculoma he found the following

findings on CT Scan, that the size

(diameter) of these lesions ranged from 1

mm to 5 cm. Eighty-six per cent of the

lesions were < 1 cm, 11% of the lesions

were 1 to 3 cm, and 3% of the lesions were

> 3 cm in diameter. On noncontrast head

CT scans, 90% of the lesions were isodense

to brain parenchyma, 7% were

hyperdense, and 3% were hypodense. The

pattern of enhancement was dependent

upon the size of the lesion. More than 90%

of the lesions < 3 mm in size showed

homogenous enhancement. Sixty per cent

of the lesions ranging from 0.3 to 1 cm in

size were ring enhancing, whereas 40%

showed homogenous enhancement.

Lesions > 1 cm in size showed varied

enhancement, including irregular shapes,

ring like shapes, open rings, and lobular

patterns. Target like lesions were seen in

only 2 patients. Calcification was present

in < 10% of the lesions. Sixteen patients

had both CT and MRI scans. CT scans

were more sensitive in the diagnosis of

calcification, where as MRI scans were

more sensitive in picking up a larger

number of lesions, infarcts, vasogenic 5oedema, and meningeal enhancement.

Our patient was started on four drug

antituberculous therapy with steroids

which emphasise the efficiency of steroids

in reducing the perilesional oedema and

threatening intracranial hypertension.

Anticonvulsant treatment is mandatory

for seizure control. The indication of

medical treatment alone is justified 5because it is safe, efficient, and cheap. In

conclusion, patients, who are suspected to

be suffering from CNS tuberculosis should

receive a prolonged (12-30 months) course

of effective antituberculous therapy. Our

patient developed severe headache with

vomiting after almost one month of

therapy, though the repeat MRI shows a

reduction in the size of the tuberculomas.

The possible immunological mechanisms

of this phenomenon are analysed.

E v i d e n c e o f n e w i n t r a c r a n i a l

tuberculomas or the expansion of older

existing lesions requires no change in the

antituberculous drug programme. In such

cases systemic dexamethasone as

adjuvant therapy for 4 to 8 weeks is 6worthwhile and effective.

References

1. Bhasakara Reddy D. AND Kameshwara Rao V.

Tuberculoma of the brain. Indian Journal of

Tuberculosis 1951 ; 2 (2): 93-98.

2. Lisa M, Deangeli S. Intracranial tuberculoma:

Case Report And Review of the Literature.

Neurology 1981; 31: 1133-1136.

3. Mohamed Maftah, Ali akhaddar, M Lmjjati, A

mansouri, Najia EL Abbadi, Foud Bellakhdar.

Intracerebral tuberculoma: (Report of 115 cases)

The Pan Arab Journal of Neurosurgery 2001; 5 :

1-50

4. C.M.Sharma, B.L.kumawat. Isolated sensory

trigeminal neuropathy - A rare clinical

presentation of brainstem tuberculoma: The

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Internet Journal Of Neurology 2009; 11:

Number 1

5. Wasay M, Kheleani BA, Moolani MK, ET AL.

Brain CT And MRI Finding in 100 consecutive

patients with intracranial tuberculoma :

Journal Of Neuroimaging 2003; 13: 240-247

6. Hejazi N, Hassler W, Rappaport Z. H. Multiple

intracranial tuberculoma with atypical response

to tuberculostatic chemotherapy. Acta

Neurochirurgica 1997; 139 : 194-202

Letters to Editor

Xpert MTB/RIF test for tuberculosis

Xpert MTB/RIF has been specifically recommended by WHO as a frontline diagnostic test in individuals and HIV co-infection. Although Xpert MTB/RIF comprehensively outperforms smear microscopy, and is thus a substantial advance over the standard of care in people with HIV infection, these data highlight the need to treat a single negative result in people with HIV infection with caution.

G. Theron, J. Peter, K. Dheda, The Lancet, 2011; Vol. 378;481

We assessed the Xpert MTB/RIF test in 90 patients with suspected pulmonary tuberculosis in a high-prevalence region of Dharamsala, India.

In seven cases, Xpert MTB/RIF identified rifampicin resistance that was not confirmed by conventional DST.

The Xpert MTB/RIF test for rifampicin resistance requires further development to achieve 100% specificity.

F. Salvo, T. Sadutsang, G. Migliori, A. Zumla, D. Cirillo, The Lancet, 2011; Vol. 378;481

We need to move on and assess its cost-effectiveness and how it will change the performance of national tuberculosis programmes in terms of detection rates and management of resistant forms of Mycobacterium tuberculosis.

Although the Xpert MTB/RIF assay is recommended for screening of drug-resistant tuberculosis and for populations infected with HIV, its high sensitivity in smear-negative cases could support other uses, such as for biomarkers of tuberculosis disease activity or cure.

G. Ferrara, J. Grady, A. Zumla, M. Maeurer, The Lancet, 2011; Vol. 378;482

Author's reply

Since no test is 100% sensitive, health workers confronted with negative results from patients with suspected disease must: (1) retest a new sample, (2) test with alternative methods, or (3) treat on

clinical bases. Xpert despite sensitivity similar to solid culture, cannot resolve this dilemma.

Fulvio Salvo and colleagues stress that the need for phenotypic drug susceptibility testing (DST) will

not disappear with Xpert implementation.

Both phenotypic and genotypic testing result in some false calls: errors in DST for rifampicin occur with a frequency of 1-3% even in supranational laboratories.

Ideally, Xpert should equal or surpass DST reliability.

Mark D Perkins, David Alland, Mark P Nicol, Pamela Nabeta, Catharina C Boehme, The Lancet,

2011;Vol. 378;481-483

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