Intracranial Tuberculoma in a Pregnant Lady: A Hitherto Unknown Case and a Successful Outcome

Abstract

Central nervous system tuberculosis (CNS-TB) is rarely suspected in pregnancy because its clinical presentation may masquerade other common conditions in pregnancy, such as eclampsia. In high tuberculosis endemic areas, CNS-TB should be suspected with a high degree of suspicion among unimmunized and immunocompromised individuals. We hereby report a case of a 32-year-old pregnant woman conceived by in vitro fertilization due to tubal blockage causing infertility, probably due to chronic infection, who presented with a history of multiple seizure episodes without a history of similar complaints outside this pregnancy. Obstetric examination revealed a gravid uterus larger than the corresponding gestational age, and an antenatal scan confirmed dichorionic diamniotic twins with the first twin in the breech and the second twin in the cephalic presentation. Magnetic resonance imaging of the brain revealed multiple nodular lesions of varying sizes that were isointense on T1-weighted imaging and hypointense on T2-weighted imaging in multiple regions of the brain, which suggest tuberculomas. A preterm cesarean section was performed at 31 weeks gestational age due to preterm rupture of membranes. We report this case to enlighten the physicians in diagnosing seizures causing intracranial tuberculoma in pregnant women and utilizing the role of imaging in diagnosis.

Cerebral tuberculoma in pregnant women: A systematic review and comprehensive analysis of literature

“…While the imaging ndings described in the literature, such as isointensity and/or hypointensity in T1, T2, and FLAIR sequences and the presence of perilesional edema, align with our observations in pregnant patients, there exist more advanced imaging modalities that enhance our diagnostic capabilities. One notable instance in our case review involved the use of Magnetic Resonance Spectroscopy (MRS) for a pregnant patient, where the analysis revealed an increased choline-creatinine ratio, decreased N-acetyl aspartate, and a lipid peak, as per the ndings reported by Vempati et al 23 . This instance underscores the utility of MRS and Gd-DTPA enhanced MR images in providing a more nuanced differential diagnosis.…”

“…Reports from other studies indicate that patients with CNS tuberculosis may present with low glucose levels and normal protein levels in the CSF, alongside low ADA activity and negative results from cartridge-based nucleic acid ampli cation 17 . Despite its poor speci city, when interpreted alongside other laboratory ndings, ADA levels ranging from 1 to 4 U/L can aid in the diagnosis Indirect diagnostic tests, including antigenic testing, the tuberculin test, and interferon-gamma release assays, were commonly used in pregnant patients and yielded a higher proportion of positive results compared to direct methods.…”

“…We included articles from 16 countries located on ve continents worldwide. The most common country of reports was China (n = 6 cases) 22 , followed by India (n = 5 cases) 3,14,18,23 , USA (n = 2 cases) 19,24 and France (2 cases) 11 . The data collection period ranged from 1975 4 to 2024 (Vinueza-pending publication).…”