Multiple intracranial tuberculomas with atypical response to tuberculostatic chemotherapy

Abstract

Approximately 34 cases of intracranial tuberculomas with paradoxical response to antituberculous chemotherapy have been documented worldwide. In most of the previously reported cases of this entity an associated tuberculous meningitis has been reported. The majority of these patients were children or young adults, who had inoperably located intracranial tuberculomas in high risk regions developing a few weeks or months after the start of appropriate chemotherapy. 53% of them recovered completely, 37% improved with mild neurological deficits and 10% died. It is interesting that these intracranial tuberculomas developed or enlarged at a stage when systemic tuberculosis was being treated successfully. We report our recent experience with these potentially curable tumours of the central nervous system. The literature is reviewed and diagnostic and therapeutic considerations are discussed. The possible immunological mechanisms of this phenomenon are analysed. In conclusion, patients, who are suspected to be suffering from CNS-tuberculosis should receive a prolonged (12-30 months) course of effective antituberculous therapy. Evidence of new intracranial tuberculomas or the expansion of older existing lesions require no change in the antituberculous drug programme. In such cases systemic dexamethasone as adjuvant therapy for 4 to 8 weeks is worthwhile and effective. Surgical intervention may be necessary in situations with acute complications of CNS tuberculosis such as shunting procedures for the treatment of hydrocephalus. When the diagnosis is not firm and there is no response to therapy within 8 weeks, a stereotactic biopsy of a suspected tuberculoma should be performed. If the largest lesion is not located in high risk deep regions of the brain, it should be total removed surgically. With this combined management, a satisfactory outcome can be obtained in the majority of cases.

Spinal Intramedullary Tuberculoma Requiring Surgical Treatment-Case Report-

“…4) In eight surgical cases of intramedullary tuberculomas, the mean time between onset and surgery was 31.5 ± 26.1 weeks. Total removal was performed in five cases, partial removal in two cases, and biopsy in one case.…”

CT Perfusion Dynamics of Intracranial Tuberculomas

“…This may be due to immunologically mediated secondary granulomatous vasculitis (with? vessel occlusion) [30].…”

Paradoxical Intracranial Tuberculoma Requiring Surgical Treatment

“…These responses are often encountered in three tissues: lymph nodes, brain and lungs [2]. In paradoxical reactions of the brain, some tuberculomas may enlarge [1,3,4,5], or new ones may develop [6,7,8,9]. Steroid therapy with antituberculous chemotherapy is generally recommended for treatment of paradoxical tuberculomas.…”

“…Despite this favorable situation, some patients present particular reactions during the course of chemotherapy which are unusual, and often unexpected. Because these reactions are noted during appropriate therapy with susceptible bacilli, they may be called paradoxical responses [1, 2]. These responses are often encountered in three tissues: lymph nodes, brain and lungs [2].…”

“…The global incidence of tuberculosis is increasing from year to year because of a high prevalence of medically underdeveloped populations, human immunodeficiency virus, alcohol and intravenous drug abusers [1]. However, results of antituberculous chemotherapy are usually well.…”