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Case Report

Concurrent occurrence of both intracranial and

intramedullary tuberculomas

Sreeramulu Diguvinti, Srinivasulu Damam, Kiran Kumar Ubara, Chennakesavulu Dara
Department of Medicine, Kurnool Medical College, Kurnool 518002, Andhra Pradesh, India.

ABSTRA CT
Tuberculosis involving spinal cord in the form of intramedullary tuberculoma is uncommon, and the concurrent occurrence of cranial
and intramedullary tuberculomas is extremely rare. We report a case of disseminated tuberculoma involving brain and spinal cord with
miliary tuberculosis in a 32-year-old male presenting with fever, cerebellar signs and motor weakness of both upper and lower extremities.
Based on magnetic resonance imaging and polymerase chain reaction, we diagnosed as tuberculoma. He completely recovered with
conventional antituberculous treatment and steroids. The follow-up of the patient showed disappearance of signs and symptoms.

Key words: Intracranial tuberculoma, intramedullary tuberculoma, magnetic resonance imaging, polymerase chain reaction

INTRODUCTION for 10 days. There was also the history of the evening
rise of temperature, loss of weight and appetite. On
Mycobacterium tuberculosis is a serious pathogen examination, he had quadriparesis with a power 4/5 in all
worldwide. Central nervous system (CNS) tuberculoma four limbs, tremors, dysarthria, dysmetria, dyssynergia,
is a rare form of extrapulmonary tuberculosis and is dysdiadochokinesia, hypotonia in all limbs, plantar
often the result of hematogenous spread from a primary response was equivocal without sensory involvement.
focus, mostly the lung. Most common manifestations of
[1]
tuberculosis in the CNS are tuberculous meningitis and On the evaluation, erythrocyte sedimentation
intracranial tuberculoma. Brain is far more commonly rate (ESR) was 40 mm/1st h, chest X-ray showed
affected than the spinal cord. Infratentorial tuberculomas military mottling [Figure 1]. Sputum examination
[2]
are more frequent in children, whereas lesions are mostly for acid fast-bacilli (AFB) could not be done as a
supratentorial in adults. Intramedullary tuberculoma patient had no cough. Mantoux test was positive and
[3]
of the spine is a rare manifestation of disseminated cerebrospinal fluid (CSF) was clear, with 4 white blood
tuberculosis, usually in young people and most commonly cell/dL (100% lymphocytes), sugar 52 mg/dL, proteins
involve the thoracic spinal cord. Its incidence is only 37 mg/dL, chloride 89 mmol/L. AFB staining was
[4]
2 out of 100,000 cases of all tuberculosis. We report a negative in CSF with adenosine deaminase activity
[5]
case of combination of intramedullary and intracranial levels of 7 IU/L. Magnetic resonance imaging (MRI)
tuberculoma which is extremely rare, so far, only five brain showed multiple well-defined ring-enhancing
cases have been reported in the literature. lesions with perilesional edema in the bilateral cerebral
and cerebellar hemispheres, midbrain, pons, medulla
CASE REPORT suggestive of tuberculomas [Figures 2 and 3]. Spine
MRI showed intramedullary ring enhancing lesions
A 32-year-old male immunocompetent patient came with affecting the cervical and dorsal regions and edema also
severe signs of unsteadiness of gait, swaying, slurred noted [Figures 4-6]. Polymerase chain reaction (PCR)
speech and heaviness in both upper and lower limbs test was positive for Mycobacterium tuberculosis.

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Based on chest X-ray, MRI and PCR, the diagnosis of
Quick Response Code: multiple tuberculomas was made.
Website:
www.nnjournal.net
DISCUSSION
DOI:
10.4103/2347-8659.153980 Central nervous system tuberculosis is rare, affecting
0.5-2% of patients with systemic tuberculosis.

Corresponding Author: Dr. Chennakesavulu Dara, Kurnool Medical College, Kurnool 518002, Andhra Pradesh, India.
E‑mail: augnus2k3@gmail.com

118 Neuroimmunol Neuroinflammation | Volume 2 | Issue 2 | April 15, 2015