Concurrent intramedullary and intracranial tuberculoma: A rare association

Tuberculous meningitis is the most common manifestation of neurotuberculosis. The incidence of spinal intramedullary tuberculoma is still an uncommon presentation even in a country like India, where the burden of tuberculosis is high. A combination of intramedullary, cerebellar, and cerebrum tuberculoma is rare. We report a case of symptomatic cervical and dorsal intramedullary tuberculoma without bladder involvement and asymptomatic cerebellar and temporal lobe tuberculoma.

Keywords: Neurotuberculosis, paraparesis, tuberculoma

Tuberculosis is one of the oldest known diseases of mankind, and it is a major burden on public health as well as a major cause of death in developing countries. The central nervous system (CNS) is involved in approximately 10% of all tuberculosis cases. ^[1] Intramedullary tuberculoma constitutes only 0.2-5% of all CNS tuberculoma cases. ^[2] Concurrent intramedullary spinal cord and intracranial tuberculoma is a very rare entity and only seven cases of such combination were reported in the literature.

A 30-year-old female patient presented with a 1-year history of acute onset of paraparesis without bladder involvement. The examination of her motor system revealed grade 3 spasticity on the modified Ashworth scale in both the lower limbs with grade 3/5 power both proximally and distally. During the examination of her sensory system, there was loss of pain, touch, and temperature below T ₄ level. There was also loss of posterior column sensation below the anterior superior iliac spine. The deep tendon reflexes of both the lower limbs as well as the upper limbs were brisk with extensor planter response. There was no evidence of cranial nerve involvement or cerebellar involvement.

Hematological examination of the patient revealed normal parameters except increased erythrocyte sedimentation rate (ESR) (24 mm) at 1 h. Her biochemical parameters were normal. Enzyme-linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV) was negative. Radiographs of her dorsal spine revealed no abnormalities. Cerebrospinal fluid (CSF) study revealed lymphocytic predominant pleocytosis (248 cells/mm ³ ) and increased protein level (565 mg/dl), and polymerase chain reaction (PCR) was positive for Mycobacterium tuberculosis.

The sagittal T2-weighted magnetic resonance imaging (MRI) revealed intramedullary hypointense lesion at the cervical (C2) and thoracic (T11) regions, and the corresponding T1-contrast image showed intramedullary ring enhancing granuloma [Figure 1]. Incidentally, we also found that there was a ring-enhancing granuloma in the cerebellum [Figure 2]. Hence, we planned for an MRI brain scan that revealed a ring enhancing conglomerated granuloma in the left temporal lobe [Figure 3]. The patient was started on an antitubercular treatment (ATT) (HRZE) along with pyridoxine. She was showing improvement with medication for weakness as well as spasticity.

Pulmonary tuberculosis is the most common manifestation of M. tuberculois. Extrapulmonary tuberculosis results from the spread of bacilli through the hematogenous route. Usually, the lung is a primary focus site. CNS tuberculosis constitutes 10% of all the cases of tuberculosis. The most common manifestation of neurotuberculosis is tuberculous meningitis, and intracranial tuberculoma is the most common manifestation of brain parenchyma. Tuberculomas can be single or multiple in nature. Involvement of the brain is far common than the spinal cord. The incidence of spinal intramedullary tuberculoma (SIT) is 2 in every 100,000 tuberculous patients. SIT constitutes 0.5-2% of all CNS tuberculosis patients. ^[2] Citow et al. ^[3] found that the ratio of the brain and spinal cord involvement was 42:1. Intramedullary tuberculoma remains an uncommon manifestation and in combination with intracranial tuberculoma, is a rare entity.

Our patient presented with acute onset symmetrical spastic motor-sensory paraparesis without bladder involvement. The MRI findings were consistent with tuberculoma as described in the literature. Tuberculomas having varying intensity on T1 and T2 depend on the content of tuberculoma. Tuberculomas are hypo- to isointense on T1-weighted image and of low intensity with or without central hyperintensity on T2-weighted image. ^[4],[5] Dorsal spine is the most common site for tuberculoma. Cysticercal granuloma, ependymoma, astrocytoma, lymphoma, and metastasis are differential diagnoses of intramedullary tuberculoma. But in view of CSF characteristics, PCR positivity, neuroimaging features, and improvement with ATT confirmed the diagnosis of tuberculoma.

Yen et al. ^[6] and Thacker et al. ^[2] also reported intramedullary tuberculoma with incidental intracranial tuberculoma like in our case. Our patient had no symptoms or sign of intracranial involvement. In literature, there are a few cases of such a combination have been reported ^{[2],[6],[7],[8],[9],[10],[11]} [Table 1]. MRI became an important tool in diagnosis as well as in monitoring of the therapy. Most of the times, intramedullary tuberculoma can be treated medically and sometimes surgically if the patient is not improving or is deteriorating clinically.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1755-6783.162392

[Figure 1], [Figure 2], [Figure 3]

[Table 1]