Brain tuberculoma in pediatric heart transplant recipient.

INTRODUCTION: Heart transplantation is the standard treatment for end-stage heart disease. Despite advances in the field, patients remain under risk of developing complications, including opportunistic infections, such as tuberculosis. We present the unprecedented case of cerebral tuberculoma in a 9-year-old heart transplant recipient. CASE SCENARIO: A 9-year-old female child, who underwent heart transplantation in December 2020, was admitted to the emergency department in September 2021 due to headache and vomiting. She had normal vital signs and a mild left hemiparesis. Laboratory findings included lymphopenia and a low C Reactive Protein and brain images showed expansive lesions. A biopsy of the intracranial lesion was performed and anatomopathological analysis was compatible with tuberculoma. After the diagnosis was established, treatment protocol for neurotuberculosis was initiated, the patient had a satisfactory clinical evolution and was discharged 22 days after admission. DISCUSSION: Clinical manifestation of tuberculosis usually occurs up to 6 months after transplantation, the findings are commonly atypical and symptoms may be mild. We could not find in medical literature any description of the disease in a heart transplant recipient as young as the one presented in this case report. We documented great response to treatment, even though conventional antituberculosis therapy may interfere with immunosuppression. CONCLUSION: Patients in the postoperative period following heart transplantation are at high risk for developing opportunistic infections such as tuberculosis, which may present with atypical symptoms. Therefore the clinician must have a high index of suspicion in order to make the correct diagnosis and promptly start treatment.

Neuromeningeal tuberculosis in HIV-negative patients: a retrospective study in Rabat, Morocco.

Neuro-Meningeal Tuberculosis (NMT) is a severe infection of the central nervous system which causes a public health problem in Morocco and in several countries in the world. In order to describe the epidemiological, clinical, paraclinical and outcome among NMT patients without HIV, we carried out a retrospective study at the neurology department of the Military Hospital of Rabat in Morocco, over a period of 17 years (2000-2017). Forty patients were included with a mean age of 44 years (± 18) and a sex ratio of 1.66. A history evoking the possibility of tuberculous origin was found in 8 patients (20%). Febrile confusion was the most common clinical manifestation and was observed in 22 patients (55%) followed by febrile meningeal syndrome in 12 patients (30%). The main abnormalities noted in brain magnetic resonance imaging (MRI) were: hydrocephalus in 13 cases (32.5%), intra-cranial tuberculomas in 10 patients (25%) and leptomeningitis in 9 cases (22.5%). Cerebrospinal fluid study found clear aspect in 29 patients (75%), direct acid fast bacilli smear examination was positive in 4 patients (10%) and positive culture in 4 patients (10%). The Polymerase chain reaction (PCR) study returned positive in 6 patients (35%) of the 17 patients tested. The outcome was good in 18 patients (45%) while 19 patients suffered from neurological sequelae (47.5%) and 3 cases of death recorded (7.5%). Febrile confusion was the most reported manifestation in our patients. Subacute onset of symptoms was the most predominant feature in our patients as reported in the literature. Our results are consistent with the literature and confirm the severity of this infectious disease, even in HIV-negative patients.

Ruptured intraventricular tuberculous brain abscess mimicking cystic neoplasm: a case report.

Central nervous system (CNS) tuberculosis is a potentially life-threatening condition that may manifest in different forms and simulate other pathologies. It rarely involves the ventricles and the occurrence of primary intraventricular tuberculous brain abscess (TBA) has exceptionally been reported. As far as we know, ruptured intraventricular TBA has not been described before. An immunocompetent 56-years-old man was admitted for sub-acute intracranial hypertension with behaviour disorders. Cranial magnetic resonance imaging (MRI) showed a cystic lesion of the third ventricle containing fluid-fluid level with biventricular hydrocephalus and debris in the occipital horns. A ruptured cystic neoplasm was first considered. The patient underwent surgery via a right transcortical transventricular approach, combining both microscope and endoscope. The puncture of the lesion brought pus and the Ziehl-Neelson (ZN) staining demonstrated acid-fast bacilli. Intraventricular tuberculous abscess is an extremely rare condition that can take an unusual radiological appearance. This observation highlights the consideration of tuberculosis within the list of differential diagnosis of intraventricular cystic lesions in immunocompetent hosts.

[A case of brain tuberculoma resembling a malignant tumor].

A 35-year-old Sudanese man experienced bitter tastes on the right side of his tongue from January 2012. He was admitted to our hospital in March 2012 because of the appearance of distress, right facial palsy, nausea, and dizziness from late February 2012. A neurological examination revealed Bruns nystagmus, which increased on rightward gaze, as well as total hypoesthesia in the distribution of the maxillary branch of the right trigeminal nerve, moderate right peripheral type facial nerve palsy, and limb ataxia on the right side. Neither muscle weakness nor sensory disturbance was observed. Slight hyperreflexia was noted in the right extremities, and bilateral plantar responses were flexor. He showed wide-based ataxic gait and was unable to do tandem gait. Brain CT scans and magnetic resonance (MR) images revealed a mass lesion in the right pons to the right middle cerebellar peduncle with ring enhancement, suggestive of a "target" sign. Laboratory tests, including hematological and biochemical analyses, tumor markers, and antibodies, had normal values while the tuberculin reaction and QuantiFERON-TB Gold were strongly positive. Cerebrospinal fluid analysis revealed a slight increase in the protein level (76 mg/dl) with a normal cell count (2 per µl), and polymerase chain reaction-based tests and cultures were negative for Mycobacterium tuberculosis three times. Right subclavicular lymph node and right adrenal gland showed accumulation of fluorodeoxyglucose on positron emission tomography-CT, as did the mass lesion in the brainstem. These findings suggested a possibility of a metastatic malignant tumor or extrapleural tuberculoma. Because of the patient's religious belief, we were unable to perform a biopsy of the lymph node, and thus administered anti-tuberculous drugs. With treatment, his neurological symptoms such as facial palsy and ataxia improved steadily except for paradoxical worsening for the initial five days, and the gadolinium-enhanced lesion shrunk markedly. Follow-up MR images demonstrated that the lesions did not expand further for 9 months. From this course of treatment, we diagnosed the patient's tumor as brainstem tuberculoma. Brain tuberculoma sometimes resembles a malignant tumor, and it is therefore challenging to diagnose brainstem tuberculosis in cases without lung lesions. It is important to make a comprehensive diagnosis based on the patient's background, imaging, and course of treatment, and to treat brainstem tuberculoma promptly.

An Intracranial Tuberculoma with Discharging Scalp Sinus.

Our report highlights a case of intracranial tuberculoma in an elderly woman with chronic discharging sinus. A 77-year-old woman had a mass lesion extending to the scalp through a chronic discharging sinus for 2 years with an intermittent, non-radiating, dull, low-grade headache. Based on our survey of central nervous system tuberculosis, this case is a rare event of documented intracranial tuberculoma with concomitant discharge of the scalp sinus similar to the periodic geyser eruptions in developing countries.

Brainstem tuberculoma: A delayed IRIS.

We describe a twenty six years old lady with tuberculous meningitis who developed new onset left ptosis and binocular diplopia with features of left fascicular 3rd nerve palsy after 9 months of anti tubercular therapy (ATT) and imaging revealed new onset tuberculoma in the mid-brain. Tuberculoma responded to steroids while continuing ATT. Formation of new tuberculoma as a part of immune reconstitution inflammatory syndrome (IRIS) is possible even after prolonged therapy of 9 months, which responded well to only steroids without altering ATT.

Othello Syndrome Secondary to Cerebral Tuberculoma: A Case Report. / Síndrome de Otelo secundario a tuberculoma cerebral: a propósito de un caso.

INTRODUCTION: Othello syndrome, an eponym of Shakespeare's character, is a transnosological diagnostic term that designates a clinical picture characterised by the presence of delusions of infidelity with respect to a partner and that, consequently, can lead to typical jealousy attitudes and violent behaviour towards the partner. In its pure form, it corresponds to delusional disorder of infidelity, but it may also be secondary to brain organicity and drug use. METHODS: Case report and non-systematic review of the relevant literature. CASE PRESENTATION: A 26-year-old man, with a history of drug abuse and a victim of domestic violence as a child, presented with tonic-clonic seizures and intracranial hypertension three years ago, for which he underwent a craniotomy with the finding of a right frontal cerebral tuberculoma. After a lapse, he developed a clinical picture of delusions of infidelity regarding his partner and violent behaviour towards her. LITERATURE REVIEW: Delusional jealousy is associated, like other delusions, with lesions of the right frontal lobe. Despite the high and growing prevalence of tuberculosis worldwide, there are no reported cases of Othello syndrome secondary to cerebral tuberculoma in the literature. CONCLUSION: Othello syndrome, although not the main cause of domestic violence, can be associated with particularly violent manifestations and be secondary to cerebral tuberculoma. This is the first published case of its kind.

Role of Surgery in Intracranial Tuberculomas and Proposal of a Novel Diagnostic Criteria for Diagnosis (Sri Venkateswara Institute of Medical Sciences Criteria).

OBJECTIVE: Intracranial tuberculomas (IT) are often misdiagnosed or overdiagnosed, resulting either in delay in treatment of this curable illness or in unnecessary surgical intervention. A new method of diagnostic criteria for preoperative diagnosis of IT is proposed. METHODS: A retrospective analysis was performed of all patients with a preoperatively suspected diagnosis of IT who were operated on at our institute from 2010 to 2019. The patients were divided into 2 groups: biopsy-proven IT and biopsy ruled out IT. Tests of diagnostic accuracy were applied for each finding. RESULTS: A total of 69 patients were operated on in the given period, 40 of whom were proved by biopsy as having tuberculoma. In the remaining 29 patients, the biopsy ruled out tuberculoma. Three features were identified as major criteria and 7 features were identified as minor criteria. We suggest that the diagnosis of IT should be made preoperatively, in the presence of 3 major criteria, 2 major and 3 minor criteria, 1 major and 5 minor criteria, or 7 minor criteria. By applying these diagnostic criteria to each of the 69 patients, we could diagnose IT in all 40 patients and exclude IT in all 29 patients preoperatively. CONCLUSIONS: We suggest that empirical antituberculous treatment should be started in a patient without the need for invasive surgery if our criteria are met. If the criteria are not met, we suggest further evaluation of the patient for an alternative diagnosis or early surgery for definitive management. Surgery decreases the duration of antituberculous treatment and helps in early resolution of lesions.

Diagnosis and management of intracranial tuberculomas: about 2 cases and a review of the literature.

Central nervous system tuberculosis is a major cause of morbidity and mortality in developing countries. Intracranial tuberculoma is rare and is one of the most severe cases of tuberculosis. We present two cases. The first one is about a girl of 7 years, followed for 5 months for lymph nodes tuberculosis on anti-TB treatment that presents generalized tonic-clonic seizures associated with progressive intracranial hypertension syndrome. Brain MRI has objectified necrotic nodules in left hemisphere. The surgical approach of the lesions was direct with complete excision. The diagnosis of tuberculoma was confirmed by anatomopathological examination. The second case is about a 6-year-old girl with no particular medical history, which presents for three months progressive and treatment-resistant cervico-occipital headaches associated with walking difficulties. The MRI objectified left cerebellar tumor process interpreted preoperatively as medulloblastoma. The patient was operated on intraoperative, appearance was that of a nodular lesion. Anatomopathological examination confirmed the diagnosis. The intracranial tuberculoma is an unusual variety of the central nervous system tuberculosis and remains a topical issue in Morocco. The prognosis depends on prompt diagnosis, quality of surgical resection and anti-TB treatment. The diagnostic confirmation is histological and should therefore be evoked infront of any intracranial process mimicking a brain tumor.

[Cerebral tuberculoma a diagnostic challenge: case study and update]. / Tuberculome cérébral un challenge diagnostic: à propos d'un cas et mise au point.

Central nervous system (CNS) tuberculosis is the second most common presentation after tuberculous meningitis. It is a major cause of morbidity and mortality in the developing countries, accounting for 10-30% of intracranial expansive lesions in these countries against 0.2% in some Western countries. This study aims to report an atypical clinical and radiological manifestation (brain MRI and spectroscopy) of cerebral tuberculoma in order to provide an update on this infectious disease. The study involved a 44-year old female patient with no particular previous history, with headaches persisting for 1 year and complicated by partial secondarily generalized seizures and heaviness at the left hemicorpus with episodes of vomiting without visual disorder or fever or deterioration of general condition after 8 months. Clinical examination showed conscious patient with Glasgow Coma Scale (GCS) 15, equal and reactive pupils, walking and/or standing without fault, with 4/5 left-sided hemiparesis without other neurological signs. Brain MRI objectified right parietal subtentorial plurilobulated isointense poorly differentiated lesion on T1 weighted sequence without contrast agents injection and heterogeneous lesion with hyperintense edge and hypointense fundus, suggesting fleshy process with areas of central necrosis and perilesionnal edema extending in finger-like fashion with intense annular enhancement after gadolinium injection on T2 weighted sequence. Spectroscopy showed glial tumor. The patient received anticonvulsant therapy and macroscopic complete resection. Anatomopathologic analysis showed cerebral tuberculoma. She received antituberculosis drugs with seizure stoppage and deficit recovery after 4 weeks. This study highlights the clinical and radiological polymorphism of cerebral tuberculoma. This is suspected based on laboratory tests as well as on a body of clinical and radiological evidences but definitive diagnosis is based on anatomopathologic analysis. Early management is essential because complications can be severe and result in a poor prognosis.

A 32-Year-Old Woman With Miscarriage, Headache, Hepatitis, and Pulmonary Disease.

CASE PRESENTATION: A 32-year-old Nigerian woman, who became pregnant after undergoing in vitro fertilization, was admitted with nausea and abdominal pain. She had a history of two miscarriages and infertility because of tubal blockage treated by salpingectomy. One week prior, she presented to an outside hospital with premature rupture of membranes resulting in stillborn delivery of twins. Endometrial cultures from dilatation and curettage grew Escherichia coli, and she was started on a fluoroquinolone for chorioamnionitis.

Tuberculoma intracerebral en gestante inmunocompetente / Intracerebral tuberculosis in pregnant immunocompetent

La tuberculosis causada por la bacteria Mycobacterium tuberculosis, se encuentra entre las 10 primeras causas de mortalidad a nivel mundial; la presentación extrapulmonar se produce por siembra vía hematógena o linfática desde un foco primario, correspondiendo a la afectación de sistema nervioso central el 5% de infecciones por TB y se presenta con menor frecuencia en personas inmunocompetentes. Las formas de tuberculosis de SNC son meningitis, tuberculosis espinal y tuberculomas que corresponden al 1% de infecciones por TB. El tratamiento se basa en la terapia antifímica, reservando el manejo neuroquirúrgico para puntuales indicaciones como deterioro neurológico, hidrocefalia o mala respuesta al tratamiento farmacológico.

Tuberculosis, caused by the Mycobacterium tuberculosis bacteria, is among the top 10 cau-ses of mortality worldwide; The extrapulmonary presentation is produced by hematogenous or lymphatic seeding from a primary focus, 5% of TB infections corresponding to central nervous system involvement and occurs less frequently in immunocompetent people. The forms of CNS tuberculosis are meningitis, spinal tuberculosis and tuberculomas that corres- pond to 1% of TB infections. The treatment is based on antifungal therapy, reserving neurosurgical management for specific indications such as neurodeterioration, hydrocephalus or poor response to pharmacological treatment

Cerebral tuberculomas in a 6-year-old girl causing central diabetes insipidus.

A 6-year-old girl presented acutely with worsening frontal headaches. She had a 3-month history of lethargy, reduced appetite, weight loss, cough and intermittent fevers. A chest X-ray showed a left upper lobe consolidation, and a CT head showed multiple enhancing lesions with significant surrounding oedema in both cerebral hemispheres. Due to the strong suspicion of tuberculosis (TB), she was admitted and treated with anti-TB therapy and steroids. Following this, pulmonary infection with Mycobacterium tuberculosis was confirmed by a positive PCR from induced sputum. Cerebral spinal fluid (CSF) analysis was normal and tested negative for M. tuberculosis on PCR. During her first week of treatment, she developed polyuria, nocturia and polydipsia and was diagnosed with central diabetes insipidus. She was started on desmopressin which rapidly improved her symptoms, and she was continued on desmopressin for 3 months. Currently, she remains well and has shown a good response to TB treatment.

Isolated Oculomotor and Abducens Nerve Palsies as Initial Presentation of Cavernous Sinus Tuberculoma: Case Report and Literature Review.

BACKGROUND: Central nervous system tuberculoma is the most severe manifestation of extrapulmonary tuberculosis with high mortality. Cavernous sinus tuberculoma (CST) is a very rare central nervous system tuberculoma with few cases reported in the literature. CASE DESCRIPTION: A 57-year-old woman was admitted to our clinic with acute diplopia and headache limited to the right side. There was no specific medical history except for migraine, depression, and anxiety, all of which were controlled by oral medications. Physical examination revealed ptosis and mydriasis in the right eye, which indicated right third and sixth cranial nerve palsies. Pituitary magnetic resonance imaging showed a right parasellar lesion at the cavernous sinus wall and ophthalmic nerve. Laboratory examinations and brain computed tomography scan showed negative findings. Initial differential diagnosis included meningioma, sarcoidosis, tuberculoma, and lymphoma. However, results of further studies, including blood and cerebrospinal fluid cultures and Mycobacterium tuberculosis DNA assay, were negative. Biopsy of the cerebral lesion was performed through the subfrontal approach, and histopathologic study confirmed CST. She was treated with a standard antituberculous regimen. After 12 months of follow-up, no cerebral or clinical findings were seen. CONCLUSIONS: CST is a rare presentation of M. tuberculosis, and the diagnosis is a difficult challenge. However, accurate diagnosis and timely treatment of CST can result in complete cure.

Multifocal Brain Lesions With Extensive Perilesional Edema in a Young Boy Returning From Kenya.

We report the case of an 8-year-old boy who presented with headaches, optic disc edema, and left eye esotropia. He had recently returned to the United States after living in Kenya for approximately 3 years. His brain magnetic resonance imaging showed multifocal lesions with significant perilesional edema seemingly out of proportion to his neurologic examination findings. With appropriate therapy there was remarkable improvement in his symptoms with reduction in size of the lesions and surrounding edema.

Evaluation of intracranial tuberculomas using diffusion-weighted imaging (DWI), magnetic resonance spectroscopy (MRS) and susceptibility weighted imaging (SWI).

OBJECTIVE:: The present study was aimed to evaluate patients of suspected intracranial tuberculomas with diffusion-weighted imaging (DWI), magnetic resonance spectroscopy (MRS) and susceptibility-weighted imaging (SWI). METHODS:: The present study evaluated 116 patients known or suspected of having central nervous system tuberculosis with advanced MRI techniques comprising of DWI, MRS and SWI in addition to the conventional MRI. RESULTS:: Apparent diffusion coefficient value of tuberculomas was not significantly different (p > 0.05) from apparent diffusion coefficient value of metastatic lesions and high-grade gliomas. MRS revealed that NAA/Cr and NAA/Cho ratios of tuberculomas were not significantly different (p > 0.05) from that of malignant brain lesions. However, Cho/Cr ratio of tuberculomas (1.36 ± 0.41) was significantly lower from that of malignant brain lesions (2.63 ± 0.99). SWI revealed a complete and regular hypointense peripheral ring in 42 cases of tuberculomas (58%) and in none of the malignant brain lesions. CONCLUSION:: DWI offers no clear advantage in differentiating tuberculomas from metastasis and gliomas. Tuberculomas may be differentiated from metastases and gliomas by their unique metabolite pattern on MRS. Presence of a complete and regular peripheral hypointense ring in SWI favors the diagnosis of tuberculomas. ADVANCES IN KNOWLEDGE:: The results from the present study suggest promising role of SWI in the discrimination of tuberculomas from metastatic brain lesions and gliomas with the presence of a complete and regular peripheral hypointense ring favoring the diagnosis of tuberculomas.