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DOI: 10.1055/s-0040-1708895
Brain Tuberculoma as a Differential Diagnosis of Single Intracranial Lesion: Case Report
Tuberculoma cerebral como diagnóstico diferencial de lesão intracraniana única: Relato de casoAddress for correspondence
Publikationsverlauf
14. August 2019
15. Januar 2020
Publikationsdatum:
06. April 2020 (online)
Abstract
Tuberculosis (TB) of the central nervous system (CNS) is considered one of the most severe forms of presentation of the disease. Although only 1% of TB cases involve the CNS, these cases represent around between 5 and 15% of extrapulmonary forms.[1] [2] Tuberculous meningitis (TBM) is the most frequent form of CNS TB. The granulomas formed in the cerebral tuberculoma may cause hydrocephalus and other symptoms indicative of a CNS mass lesion. In the absence of active TB or TBM, the symptoms may be interpreted as indicative of tumors.[3] [4] The prognosis is directly related to the early diagnosis and proper treatment installation.[5] We report the case of a patient with intracranial hypertension syndrome, expansive mass in the parieto-occipital region, accompanied by a lesion in the rib, initially thought to be a metastatic lesion, although posteriorly diagnosed as a cerebral tuberculoma.
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Resumo
A tuberculose (TB) do sistema nervoso central (SNC) é considerada uma das formas mais graves de apresentação da doença. Embora apenas 1% dos casos de TB envolvam o SNC, isto representa aproximadamente entre 5 e 15% das formas extrapulmonares.[1] [2] A meningite tuberculosa é a forma mais frequente de TB do SNC. Os granulomas formados no tuberculoma cerebral podem causar hidrocefalia e outros sintomas indicativos de lesão com efeito de massa no SNC. Na ausência de TB ativa ou meningite tuberculosa, os sintomas podem ser interpretados como indicativos de tumores intracranianos.[3] [4] O prognóstico está diretamente relacionado ao diagnóstico precoce e instalação adequada do tratamento.[5] Relatamos o caso de um paciente com síndrome de hipertensão intracraniana, formação expansiva em região parieto-occipital esquerda, acompanhada por lesão em arco costal, inicialmente tida como metástase, com posterior diagnóstico de tuberculoma cerebral.
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Introduction
Tuberculosis (TB) of the central nervous system (CNS) has an incidence of 10 to 30%, predominating in developing countries.[1] [2] [3] The main route of dissemination of Mycobacterium tuberculosis is hematogenic, coming from a distant focus, usually the lungs.[4] [5] The usual patient is a child or young adult with headache, seizures, progressive motor deficits and/or signs and symptoms of elevated intracranial pressure. Most patients have no symptoms of systemic infection or signs of meningitis.[6] [7] [8] [9] In the absence of active TB or tuberculous meningitis (TBM), the symptoms of tuberculomas can be interpreted as indicative of tumors.[10] [11] Due to what has been described, we report the rare case of a patient with TB of the CNS, who presented an unusual clinical and radiological onset of symptoms.
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Case Report
An 82-year-old male patient developed progressive left parieto-occipital headache, 3 months prior to admission, associated with visual agnosia and vertigo, evolving to worsening of the headache, associated with the previous symptoms. Beyond that, he did not present any alteration at the general physical and neurological examination and was hospitalized for evaluation.
Brain magnetic resonance imaging (MRI) evidenced an expansive formation in the cortical left parieto-occipital region with apparent dural implantation and a thick and irregular peripheral impregnation by the contrast, suggesting parenchymal infiltration. The lesion measured 4.7 × 4.1 × 2 cm, with extensive vasogenic edema in the adjacent parenchyma, midline shift to the right of 0.5 cm, and regular meningeal thickening ([Fig. 1A-D]). A computed tomography (CT) of the abdomen showed enlargement of the retroperitoneal lymph nodes and an unspecific renal lesion. Furthermore, a thoracic CT scan presented osteolytic lesion in one left rib. Added to swollen lymph nodes and the image findings, the primary hypothesis for the intracranial lesion was metastatic lesion, and the patient was referred for neurosurgical therapy.
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The patient was submitted to resection of the brain lesion, through microsurgical technique. The postoperative CT scan confirmed complete resection of the lesion, with remaining adjacent edema at the lesion site. A follow-up MRI was performed 90 days after the surgery, confirming the excision of the lesion, as well as reduction in the preoperative edema ([Fig. 1E-H]) The histological study was negative for any neoplastic lesion, evidencing a chronic granulomatous inflammatory process and caseous necrosis, characteristic of cerebral tuberculoma. Also, the biopsy performed in the rib lesion evidenced the presence of M. tuberculosis ([Fig. 2A-D]).
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Treatment with tuberculostatic agents (rifampicin, isoniazid and pyrazinamide) was then started. After 3 months, the patient presented a significant improvement of the whole clinical scenario, referring only occasional visual disturbance.
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Discussion
Tuberculosis is among the most lethal infectious diseases worldwide. Primarily as a disease of the respiratory tract, CNS TB represents between 5 and 15% of extrapulmonary disease. These cases present the highest rates of morbidity and mortality.[10] [12] [13] [14] Central nervous system TB can be classified into three categories: tuberculous meningitis (TBM), spinal arachnoiditis, and cerebral tuberculoma, as the case presented.[6] [13]
Any recent or remote disseminated bacillemia of TB can originate deep-seated tubercles in the brain and develop conglomerate caseous focus, known as tuberculomas. The lesions are formed by the interaction between the immune response of the host and the mycobacterial pathogen, covered with a fibrous encapsulation.[6]
These granulomas have the potential to cause all the symptoms of a CNS mass lesion, as hydrocephalus, headache, vomiting, drowsiness, papilledema, hemiparesis or seizures.[6] [10] They can present as focal neurological deficits without evidence of any systemic disease.[15] [16] Headache is among the most common symptoms, and in the case described, it was located in the left parieto-occipital region with progressive increase of its intensity, as observed in 80% of the cases.[17]
Regarding the lesion site, two thirds of the CNS tuberculomas are located in the cerebellum and one third in the cerebral hemispheres and, among the hemispherical locations, the predominance occurs in the frontal and parietal lobes.[18] The differential diagnosis can include any mass lesion, such as malignant lesions, sarcoidosis, cysticercosis, toxoplasmosis and pyogenic abscess.[15] [16] [19] [20]
The correct diagnosis is important for an early start of the treatment and to achieve better outcomes. The imaging findings are not specific, which reinforces the need to consider the clinical presentation of the patient and the epidemiology of the region, which are enough to elaborate the presumptive diagnosis. On CT scan, a nodular enhancing lesion, with a central hypodense region is characteristic. On MRI, the early stage of focal cerebritis is marked by edema and poor-defined enhancement, while in the later mature stage, central hypointensity and peripheral enhancement on T2- weighted images are evidenced.[4] [6] [21] [22] Although the diagnosis can be made on the basis of clinical and epidemiological considerations, a needle stereotactic biopsy may be considered if necessary.[6]
It is not possible to differentiate granulomas from other brain expansive lesions on the basis of neurological symptoms, since these depend basically on the site and size of the lesion.[11] [23] Signs and symptoms of intracranial hypertension and seizures are frequent manifestations.[24] [25]
The usual presentation of a tuberculoma on a brain CT scan is a hypodense or slightly hyperdense nodule, representing the central area of caseous necrosis and an enhancing halo of epithelioid cells, surrounded by a hypodense area of edema, as shown in our case. The contrast can evidence the presence of multiple lesions and complications of tuberculous meningitis. During the antibiotic treatment, serial CT scans show progressive regression of the size of the lesion.[26] None of the imaging methods, including brain MRI, can accurately differentiate tuberculomas from other intracranial masses.[27] [28] However, some authors have suggested that the presence of a central area of calcification (“target sign”) could be pathognomonic of tuberculomas.[29]
Anti-tuberculous agents (ATTs) should be initiated in any case with important clinical suspicion, rather than delayed until the confirmed diagnosis. The four first line ATTs include isoniazid, rifampicin, pyrazinamide, and ethambutol or streptomycin. The duration of the treatment ranges from 9 to 12 months, which can be extended beyond the resolution of the symptoms and of the radiographic lesions. The Bacillus Calmette-Guérin (BCG) vaccination reduces the incidence of a new tuberculoma.[10]
Neurosurgical evaluation should be performed immediately in patients with elevated intracranial pressure (ICP).[6] Tuberculomas may require surgical resection to treat the mass effect, since immediate removal offers improvement in the overall outcome, including cases of drug resistance or paradoxical worsening, an event that occurs in up to 25% of treated TB patients. The surgical approach can vary, due to the location tuberculoma of the surrounding vascular, nerve, and cortical structures, and the preference of the surgeon.[10]
Besides that, lumbar puncture can alleviate elevated ICP in communicating hydrocephalus, while ventriculoperitoneal shunting may be the most appropriate treatment for noncommunicating hydrocephalus.[10] Moreover, steroids are useful when cerebral edema produces altered mental status or focal neurologic deficits. Finally, the prognosis is better when treatment begins before the development of focal neurologic signs and altered state of consciousness.[6]
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Conclusion
Cerebral tuberculoma prognosis has improved dramatically during the last several decades, from a nearly fatal diagnosis to over 80% survival with timely treatments. Awareness of tuberculoma must be maintained when assessing CNS masses, including patients with no history of tuberculosis disease elsewhere, to ensure appropriate treatment.[10] [13]
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Conflict of Interests
The authors have no conflict of interests to declare.
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References
- 1 Anderson JM, Macmillan JJ. Intracranial tuberculoma--an increasing problem in Britain. J Neurol Neurosurg Psychiatry 1975; 38 (02) 194-201
- 2 Dastur HM, Desai AD. A comparative study of brain tuberculomas and gliomas based upon 107 case records of each. Brain 1965; 88 (02) 375-396
- 3 Mathai KV, Chandy J. Tuberculous infections of the nervous system. Clin Neurosurg 1966; 14: 145-177
- 4 Dastur DK, Manghani DK, Udani PM. Pathology and pathogenetic mechanisms in neurotuberculosis. Radiol Clin North Am 1995; 33 (04) 733-752
- 5 D'Giano CH, Fernández Boan O, Rey RC, Scornik J, Figini HA, Garcea DO. [7 cases of intracranial tuberculoma]. Medicina (B Aires) 1985; 45 (06) 649-653
- 6 Leonard JM. Central Nervous System Tuberculosis. Microbiol Spectr 2017; 5 (02) 17-44
- 7 Traub M, Colchester AC, Kingsley DP, Swash M. Tuberculosis of the central nervous system. Q J Med 1984; 53 (209) 81-100
- 8 Bagga A, Kalra V, Ghai OP. Intracranial tuberculoma. Evaluation and treatment. Clin Pediatr (Phila) 1988; 27 (10) 487-490
- 9 Harder E, Al-Kawi MZ, Carney P. Intracranial tuberculoma: conservative management. Am J Med 1983; 74 (04) 570-576
- 10 DeLance AR, Safaee M, Oh MC. , et al. Tuberculoma of the central nervous system. J Clin Neurosci 2013; 20 (10) 1333-1341
- 11 Ildan F, Gürsoy F, Gül B, Boyar B, Kihiç C. Intracranial tuberculous abscess mimicking malignant glioma. Neurosurg Rev 1994; 17 (04) 317-320
- 12 Capone D. , et al. Extrapulmonar Tuberculose. Rev Hosp Univ Pedro Ernesto 2006; 5 (02) 54-67
- 13 Barroso EC. , et al. Tuberculoma cerebral. J Bras Pneumol 2002; 28 (85) 55-58
- 14 World Health Organization. Global tuberculosis control. In: World Health Organization report 2011. Geneva: World Health Organization; 2011: 1-258
- 15 Monteiro R, Carneiro JC, Costa C, Duarte R. Cerebral tuberculomas - A clinical challenge. Respir Med Case Rep 2013; 9 (01) 34-37
- 16 Sahaiu-Srivastava S, Jones B. Brainstem tuberculoma in the immunocompetent: case report and literature review. Clin Neurol Neurosurg 2008; 110 (03) 302-304
- 17 Hejazi N, Hassler W. Multiple intracranial tuberculomas with atypical response to tuberculostatic chemotherapy: literature review and a case report. Acta Neurochir (Wien) 1997; 139 (03) 194-202
- 18 Costa FAO, Silva SHF, Fabião Neto OM, Jorge VM, Silva MMG, Balzano PC. Tuberculoma cerebral simulando neoplasia. Arquivos Brasileiros de Neurocirurgia 1995 14.
- 19 Rock RB, Olin M, Baker CA, Molitor TW, Peterson PK. Central nervous system tuberculosis: pathogenesis and clinical aspects. Clin Microbiol Rev 2008; 21 (02) 243-261
- 20 Ogbole GI, Bassey OS, Okolo CA, Ukperi SO, Ogunseyinde AO. Testicular tuberculosis presenting with metastatic intracranial tuberculomas only: a case report. J Med Case Reports 2011; 5: 100
- 21 Weisberg LA. Granulomatous diseases of the CNS as demonstrated by computerized tomography. Comput Radiol 1984; 8 (05) 309-317
- 22 Whelan MA, Stern J. Intracranial tuberculoma. Radiology 1981; 138 (01) 75-81
- 23 Alamé T, Keller K, Michel O, Sergysels R. Hyperthermia occurring with paradoxical development of cerebral tuberculomas. Respiration 1996; 63 (06) 381-383
- 24 Carbajal JR, Torres LM, Tosi PL. , et al. Tuberculoma cerebral: estudio clínico y radiográfico de 31 casos. Gac Med Mex 1986; 122: 205-211
- 25 Dao DA, Lee PW, Roy TM. Intracranial tuberculoma. J Ky Med Assoc 1990; 88 (03) 121-124
- 26 Castaêda C, Rivera H, Hinostroza E. Tuberculoma cerebral: correlato clínico-tomográfico y evaluación del tratamiento. Rev Med Inst Peru Segur Soc 1994; 3: 7-13
- 27 Bouchama A, al-Kawi MZ, Kanaan I. , et al. Brain biopsy in tuberculoma: the risks and benefits. Neurosurgery 1991; 28 (03) 405-409
- 28 Martínez-Vázquez C, Bordón J, Rodríguez-González A. , et al. Cerebral tuberculoma--a comparative study in patients with and without HIV infection. Infection 1995; 23 (03) 149-153
- 29 Bargalló J, Berenguer J, García-Barrionuevo J. , et al. The “target sign”: is it a specific sign of CNS tuberculoma?. Neuroradiology 1996; 38 (06) 547-550
Address for correspondence
-
References
- 1 Anderson JM, Macmillan JJ. Intracranial tuberculoma--an increasing problem in Britain. J Neurol Neurosurg Psychiatry 1975; 38 (02) 194-201
- 2 Dastur HM, Desai AD. A comparative study of brain tuberculomas and gliomas based upon 107 case records of each. Brain 1965; 88 (02) 375-396
- 3 Mathai KV, Chandy J. Tuberculous infections of the nervous system. Clin Neurosurg 1966; 14: 145-177
- 4 Dastur DK, Manghani DK, Udani PM. Pathology and pathogenetic mechanisms in neurotuberculosis. Radiol Clin North Am 1995; 33 (04) 733-752
- 5 D'Giano CH, Fernández Boan O, Rey RC, Scornik J, Figini HA, Garcea DO. [7 cases of intracranial tuberculoma]. Medicina (B Aires) 1985; 45 (06) 649-653
- 6 Leonard JM. Central Nervous System Tuberculosis. Microbiol Spectr 2017; 5 (02) 17-44
- 7 Traub M, Colchester AC, Kingsley DP, Swash M. Tuberculosis of the central nervous system. Q J Med 1984; 53 (209) 81-100
- 8 Bagga A, Kalra V, Ghai OP. Intracranial tuberculoma. Evaluation and treatment. Clin Pediatr (Phila) 1988; 27 (10) 487-490
- 9 Harder E, Al-Kawi MZ, Carney P. Intracranial tuberculoma: conservative management. Am J Med 1983; 74 (04) 570-576
- 10 DeLance AR, Safaee M, Oh MC. , et al. Tuberculoma of the central nervous system. J Clin Neurosci 2013; 20 (10) 1333-1341
- 11 Ildan F, Gürsoy F, Gül B, Boyar B, Kihiç C. Intracranial tuberculous abscess mimicking malignant glioma. Neurosurg Rev 1994; 17 (04) 317-320
- 12 Capone D. , et al. Extrapulmonar Tuberculose. Rev Hosp Univ Pedro Ernesto 2006; 5 (02) 54-67
- 13 Barroso EC. , et al. Tuberculoma cerebral. J Bras Pneumol 2002; 28 (85) 55-58
- 14 World Health Organization. Global tuberculosis control. In: World Health Organization report 2011. Geneva: World Health Organization; 2011: 1-258
- 15 Monteiro R, Carneiro JC, Costa C, Duarte R. Cerebral tuberculomas - A clinical challenge. Respir Med Case Rep 2013; 9 (01) 34-37
- 16 Sahaiu-Srivastava S, Jones B. Brainstem tuberculoma in the immunocompetent: case report and literature review. Clin Neurol Neurosurg 2008; 110 (03) 302-304
- 17 Hejazi N, Hassler W. Multiple intracranial tuberculomas with atypical response to tuberculostatic chemotherapy: literature review and a case report. Acta Neurochir (Wien) 1997; 139 (03) 194-202
- 18 Costa FAO, Silva SHF, Fabião Neto OM, Jorge VM, Silva MMG, Balzano PC. Tuberculoma cerebral simulando neoplasia. Arquivos Brasileiros de Neurocirurgia 1995 14.
- 19 Rock RB, Olin M, Baker CA, Molitor TW, Peterson PK. Central nervous system tuberculosis: pathogenesis and clinical aspects. Clin Microbiol Rev 2008; 21 (02) 243-261
- 20 Ogbole GI, Bassey OS, Okolo CA, Ukperi SO, Ogunseyinde AO. Testicular tuberculosis presenting with metastatic intracranial tuberculomas only: a case report. J Med Case Reports 2011; 5: 100
- 21 Weisberg LA. Granulomatous diseases of the CNS as demonstrated by computerized tomography. Comput Radiol 1984; 8 (05) 309-317
- 22 Whelan MA, Stern J. Intracranial tuberculoma. Radiology 1981; 138 (01) 75-81
- 23 Alamé T, Keller K, Michel O, Sergysels R. Hyperthermia occurring with paradoxical development of cerebral tuberculomas. Respiration 1996; 63 (06) 381-383
- 24 Carbajal JR, Torres LM, Tosi PL. , et al. Tuberculoma cerebral: estudio clínico y radiográfico de 31 casos. Gac Med Mex 1986; 122: 205-211
- 25 Dao DA, Lee PW, Roy TM. Intracranial tuberculoma. J Ky Med Assoc 1990; 88 (03) 121-124
- 26 Castaêda C, Rivera H, Hinostroza E. Tuberculoma cerebral: correlato clínico-tomográfico y evaluación del tratamiento. Rev Med Inst Peru Segur Soc 1994; 3: 7-13
- 27 Bouchama A, al-Kawi MZ, Kanaan I. , et al. Brain biopsy in tuberculoma: the risks and benefits. Neurosurgery 1991; 28 (03) 405-409
- 28 Martínez-Vázquez C, Bordón J, Rodríguez-González A. , et al. Cerebral tuberculoma--a comparative study in patients with and without HIV infection. Infection 1995; 23 (03) 149-153
- 29 Bargalló J, Berenguer J, García-Barrionuevo J. , et al. The “target sign”: is it a specific sign of CNS tuberculoma?. Neuroradiology 1996; 38 (06) 547-550
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