Role of Immuno-Polymerase Chain Reaction (I-PCR) in Resolving Diagnostic Dilemma Between Tuberculoma and Neurocysticercosis: A Case Report

Abstract

Patient: Female, 17Final Diagnosis: Tuberculous meningitisSymptoms: Headache • vomiting • loss of appetiteMedication: —Clinical Procedure: —Specialty: Infectious DiseasesObjective:Unusual clinical courseBackground:Tuberculoma and neurocysticercosis (NCC) often show similar clinical and neuroimaging features. Differential diagnosis of these 2 diseases is imperative, as tuberculoma is an active infection that requires immediate anti-tubercular therapy (ATT).Case Report:We present the case of a 17-year-old Indian girl with fever, severe headache, and right 6th cranial nerve palsy. Brain magnetic resonance imaging (MRI) showed multiple tiny ring-enhancing lesions in bilateral cerebral parenchyma with mild perilesional edema, which were initially thought to be NCC, but subsequently were diagnosed as brain tuberculomas. Based on clinical findings, mildly increased choline/creatine ratio (1.35) with slight prominent lipid lactate peak and absence of alanine, succinate peak by magnetic resonance spectroscopy (MRS), and the detection of Mycobacterium tuberculosis (Mtb)-specific early-secreted antigenic target-6 (ESAT-6, Rv3875) protein from the cerebrospinal fluid (CSF) by indirect ELISA, as well as indirect immuno-PCR (I-PCR) assay, diagnosis of brain tuberculomas associated with tuberculous meningitis (TBM) was confirmed, which was followed by ATT. The patient responded well and the symptoms resolved.Conclusions:In this case, multiple ring-enhancing lesions of the brain by MRI were diagnosed as tuberculomas associated with TBM by MRS and indirect ELISA/I-PCR method, thus resolving the diagnostic dilemma.

Brain tuberculoma: a 52-year-old woman case report

“…Tuberculomas are generally solitary, but multiple nodular ring-like enhancing lesions similar to NCC are also found in 15–34 % of CNS TB, which often confuse the diagnosis [ 18 ]. In a study by Sonia Ahlawat et al, I-PCR based on ESAT-6 detection in CSF was more sensitive in comparison to conventional microbiological (smear/culture) and molecular-PCR tests for the diagnosis of cerebral tuberculomas [ 19 ]. I-PCR has been documented to be a rapid, robust and highly sensitive method for the detection of mycobacterial antigens up to picogram levels from sputum and pleural fluids of Tb patients [ 19 ].…”

Neurocysticercosis Diagnosed by Taenia solium PCR on Brain Biopsy

“…Similarly, granulomatous inflammation on histology is nonspecific and has a wide range of possible infective and noninfective aetiologies [ 8 ]. Accurate diagnosis is vital for the administration of prompt, directed therapy, and to avoid delays in treatment for malignant or other infective aetiologies such as nocardiosis or tuberculosis [ 9 ]. In this case, definite diagnosis using PCR allowed for early tailoring of therapy, avoiding a prolonged course of empiric antituberculous drugs with its potential associated toxicities.…”