Bilateral ptosis without upward gaze palsy: Unusual presentation of midbrain tuberculoma

Abstract

Central nervous system tuberculoma can have variable presentations depending on the site and number of tuberculomas. We are reporting a rare case of an 11-year-old male child presenting with ptosis and ataxia. Clinical examination revealed bilateral partial 3rd cranial nerve palsy (ptosis without any upward gaze palsy) associated with dysdiadochokinesia and ataxia on the right side. Magnetic resonance imaging of the brain revealed a single ring-enhancing lesion in the dorsal midbrain with perifocal edema. Magnetic resonance spectroscopy provided the etiological information as tuberculoma.

Commentary

“…Neurotuberculosis accounts for 5-15% of extrapulmonary tuberculosis cases and commonly affects the hemispheres of the brain or the cerebellum. [1,2] The presence of an isolated brainstem tuberculoma is an unusual complication of central nervous system tuberculosis and its location at midbrain level is unique. [2] The semiology resulting from the lesion when the brainstem involved varies widely and may include the cranial nerves and neurological long tracts.…”

“…In this Journal issue, the authors describe an 11-year-old boy presenting with a solitary ring enhancing lesion in the midbrain with pronounced perifocal edema. [1] Magnetic resonance spectroscopy ( 1 H-MRS) was notable for increased lipid peak that led to a diagnosis of central nervous system (CNS) tuberculoma. Empirical antituberculosis (TB) treatment resulted in clinical improvement that was sustained at 18 months follow-up.…”

“…Furthermore, due to a high prevalence rate of drug resistance, universal drug susceptibility testing of M. tuberculosis is strongly recommended by the World Health Organization. [1] It is estimated that 3.3% of new TB cases are multidrug-resistant TB (MDR-TB), and of these, 9.7% of patients have extensively drug-resistant TB defined as MDR-TB plus resistance to at least one fluoroquinolone and a second-line injectable medication. [2] Therefore, drug susceptibility of M. tuberculosis should be considered when choosing treatment regimen.…”

Commentary

“…That is why early and correct etiological diagnosis are essential to provide adequate treatment[127] as described in the case report of this issue of Journal of Neurosciences in Rural Practice, in which proper administration of tuberculostatic treatment to the patient was effective and resolved the midbrain tuberculoma, an unusual clinical presentation of central nervous system tuberculosis. [7]…”

The clinical variability of midbrain lesions

“…In the paper “Bilateral ptosis without upward gaze palsy-unusual presentation of midbrain tuberculoma,”[4] Sarkar et al . describe a very interesting case of a young patient affected by midbrain tuberculoma with ataxia and ptosis.…”