Cerebral tuberculomas – A clinical challenge

Abstract

Cerebral tuberculomas are a rare and serious form of tuberculosis (TB) due to the haematogenous spread of Mycobacterium Tuberculosis (MT). Symptoms and radiologic features are nonspecific, leading sometimes to misdiagnosis. Anti-TB drugs are essential for the successful treatment of cerebral tuberculomas but there is no agreement regarding the duration of therapy.The authors present a case of a 55 years old male, presented to the emergency room with sudden onset of diplopia. Cerebral computerized tomography revealed multiple brain lesions, with contrast enhancement and peri-lesional oedema. The patient was HIV negative and because of previous malignancy the first suspicion was metastatic disease. Cultural exam of the bronchial wash showed MT sensitive to all first-line drugs. The patient started antituberculosis treatment with 4 drugs (HRZE) for 2 months, followed by maintenance therapy (HR). Treatment was prolonged for 24 months because at 12th and 18th months of treatment one of the brain lesions, although significantly smaller, still showed contrast enhancement.Even though it is not clear if contrast enhancement lesions represent active lesions or just inflammation, continuing treatment until total resolution of the tuberculomas is probably prudent.

An Atypical Presentation of Tuberculomas in an Immunocompetent Host

“…5 In our patient, despite our high clinical suspicion for TB, the pleural biopsy we obtained took 6 weeks to grow M tuberculosis. …”

“…5 Tuberculomas within the brain are usually treated pharmacologically and not with surgery as this may seed meningitis. Surgical intervention is indicated if the lesions are at risk of causing obstructive hydrocephalus.…”

Calvarial Tuberculosis with Multiple Intracranial Tuberculomas: A Rare Association in a Severely Malnourished Child with Disseminated Tuberculosis

“…Although it is not clear if this represents an active lesion or just inflammation, continuation of treatment is prudent. 6 Total resolution is demonstrated by no enhancing lesions or only an area of calcification. 6 The treatment duration should be tailored to radiological response.…”

“…2 For CNS tuberculomas, 12 months of ATD treatment is recommended. 6 Even after 12 months of therapy, two-thirds of the patients still have contrast-enhancing lesions. Although it is not clear if this represents an active lesion or just inflammation, continuation of treatment is prudent.…”

“…2 They are multiple only in 15 to 33% of the cases. 6 Cerebrum and cerebellum are usually involved due to the rich blood supply and only 4% are located in the brainstem. 5 Association of calvarial tuberculosis with tuberculomas is extremely rare, 7 but there are reports documenting spread of calvarial tuberculosis to meninges and parenchyma leading to the formation of extradural and subdural collection, brain abscess, and superior sagittal sinus thrombosis.…”