Tuberculoma masquerading as an en plaque Meningioma leading to a Diagnostic and Therapeutic Dilemma; a Case Report and a Multidisciplinary Perspective

Abstract

Introduction: Reports of an imaging or pathological diagnosis of en-plaque tuberculoma are limited. To our knowledge, descriptions of en-plaque tuberculoma are limited to a cluster of few cases, and this is the only reported case from Ethiopia. This report includes a follow-up course of the patient after neurosurgical intervention and admission to our neurology ward. Case Presentation: We present a 40-year-old Ethiopian woman, who came to our hospital with a complaint of a one-year history of global-type headache, projectile vomiting, blurring of vision, and diplopia, followed by a change in behavior of four months duration. Apart from obesity, the patient had no family or personal history of chronic illness and denied constitutional symptoms. Her neurological examination was notable for CN VI Palsy and was otherwise unremarkable. Brain MRI done at the time revealed a right frontoparietal dural-based ill-defined contrast-enhancing non-restricting mass likely representing en plaque tumor (meningioma) (with dural and leptomeningeal involvement) while CNS Tuberculosis and Sarcoidosis were considered as differential diagnoses. After evaluation by our neurosurgical team, the patient underwent craniotomy and gross total resection (GTR), after which the excised mass was sent for a neuropathologic diagnosis. The pathologic section showed fragments of large areas of necrosis, multinucleated giant cells, and well-formed epithelioid granulomas, suggestive of Tuberculosis. Her postoperative course was complicated by hospital-acquired infections, drug-induced liver injury (DILI), and renal failure, culminating in her demise. Conclusion: The present case describes a patient with CNS Tuberculosis having an atypical presentation, leading to the entertainment of an alternate diagnosis. This case highlights the fact that TB continues to masquerade as other diseases, even in the 21st century. Beyond the high index of suspicion needed to rightly diagnose our patients, appropriate interventional diagnostic tools (like stereotactic brain biopsy) are required for a subsequent management plan.