Intracranial manifestations of central nervous system tuberculosis in children.

Tuberculosis remains a significant global health challenge, with central nervous system tuberculosis (CNS-TB) posing a substantial threat, accounting for 1-10% of all tuberculosis cases. This article explores the diverse manifestations of CNS-TB in children, with a particular focus on tuberculous meningitis and tuberculomas, as well as their associated complications. Diagnostic imaging, including CT and MRI, plays a crucial role in the early detection of CNS-TB. The article emphasizes the pivotal role of imaging in the diagnosis and management of these manifestations, underscoring the importance of early recognition by healthcare professionals. Ultimately, raising awareness among pediatric radiologists, pediatricians, and pediatric neurologists is crucial for prompt intervention and improved outcomes in cases of CNS-TB.

Imaging of Pulmonary Miliary Tuberculosis With Multiple Intracranial Tuberculomas.

Tuberculosis, caused by Mycobacterium tuberculosis, is a widely spread disease complex affecting multiple organs. It is a type of communicable disease disproportionately affecting low and middle-income countries. The imaging modality of choice for pulmonary tuberculosis is computed tomography, and for brain lesions, it is a contrast-enhanced magnetic resonance imaging study. This report presents the case of a 73-year-old male patient who was diagnosed with tuberculosis on radiography and was started anti-tubercular treatment for the same and later developed multiple tuberculomas. This report showcases the imaging findings and emphasizes the need for timely and undisrupted treatment for tuberculosis management to prevent further complications like brain tuberculomas as developed in our case.

Giant cerebral tuberculoma mimicking tumor in a pediatric patient: A case report.

Tuberculosis (TB) is an infection caused by Mycobacterium tuberculosis, an infectious disease endemic in developing countries. Indonesia is ranked second only to India in terms of TB incidence in the world. TB generally manifests in the respiratory system, which can then spread hematogeneously or lymphogeneously to extrapulmonary organs. Intracranial tuberculoma is a rare manifestation of TB when compared to the overall TB presentation. Central nervous system involvement ranges from 2-5% and increases to 15% in cases of AIDS-related TB, with the percentage of tuberculoma findings around 1% in other intracranial TB cases. The most common manifestation is tuberculous meningitis. Central nervous system (CNS) involvement is a severe manifestation of TB, with high mortality and neurological morbidity. In this case report, the author presented a 6-year-old girl with giant cerebral tuberculoma, which, at the time of surgery, resembled a neoplasm with a nonspecific history of TB. MRI can visualize abnormalities with specific characteristics; Clinically and radiologically, CNS TB can mimic other infections or noninfectious conditions such as neoplasms. Therefore, clinicians can take appropriate management actions in order to prevent mortality and disability due to sequelae in CNS TB cases.

Intramedullary cervical spinal cord tuberculoma: A rare cause of paraparesis.

Neurological manifestations of tuberculosis remain rare, even if recent years have been marked by an increase in these pathologies, notably due to the HIV pandemic. Intramedullary tuberculoma remains an exceptional localization. Magnetic resonance imaging in diagnosing intramedullary tuberculoma and specific medical treatment are of great interest. We report a case of cervical intramedullary tuberculoma in a 45-year-old woman, with a slow spinal cord compression syndrome. The nature diagnosis had been retained on a clinical and radiological basis, and appropriate medical treatment was established, without resorting to surgery.

Multiple Cystic Brain Infection: A Diagnostic Dilemma of Neurocysticercosis and Intracranial Tuberculoma.

Neurocysticercosis (NCC) is a central nervous system infection caused by Taenia solium or pork tapeworm. It affects millions worldwide and represents a leading cause of epilepsy in developing countries. NCC may be challenging to distinguish from intracranial tuberculomas, with tuberculosis being highly prevalent in developing countries. We highlight the importance of clinical history, including exposure history and neuroimaging, in obtaining an accurate diagnosis to enable prompt treatment. This report presents the case of a 26-year-old man diagnosed with NCC and presenting with acute giddiness and headache. Otherwise, there was no history of fever or constitutional symptoms. Neuroimaging demonstrated multiple cerebral lesions over both hemispheres, with degenerating scolex on brain MRI. He recovered well following a combination of oral albendazole, praziquantel, and corticosteroids. This case highlights the salient features that distinguish NCC from intracranial tuberculoma. Early and precise diagnosis will ensure that patients receive optimal treatment, expedite recovery, and prevent further complications.

Diagnostic delay in ankle and foot tuberculosis resulting in tuberculoma and tuberculous meningitis in a middle-aged female: A case report.

A middle-aged woman presents with chronic foot arthritis which progressed to a non-healing ulcer, which was unresponsive to conventional antibiotics and debridement. She then developed cerebral manifestations and was empirically treated with antitubercular medications which led to healing of the ulcer. Unfortunately, delays in initiating treatment resulted in development of other extrapulmonary tuberculosis complications such as cerebral tuberculoma with tuberculous meningitis. She was subsequently diagnosed with neurocysticercosis which continued to worsen during her hospital stay. She eventually succumbed to her illness due to the complications and a possible nosocomial infection. This case highlights the challenges with diagnosis of uncommon presentations of common diseases in an endemic area, leading to diagnostic delays and development of serious complications.

Disseminated Extrapulmonary Tuberculosis in an Immunocompetent Individual Without Pulmonary Involvement: A Case Report.

Tuberculosis (TB) is a major global health burden, particularly in developing countries like India. While the most common presentation is pulmonary TB, extrapulmonary TB involving other body systems can also occur, posing diagnostic challenges. We present the case of a 24-year-old immunocompetent man from India who exhibited an uncommon and complex presentation of disseminated extrapulmonary TB. The patient had an asymptomatic brain cavitated lesion, likely tuberculoma, cervical lymphadenopathy, a small subcutaneous collection in the neck, a destructive lytic lesion in the sacrum, and a subcutaneous collection in the left gluteal/paraspinal region, all in the absence of pulmonary involvement. This combination of manifestations has not been previously reported. The presence of cervical lymphadenopathy and a slowly growing subcutaneous abscess were important clues that guided the diagnostic workup. Maintaining a high index of suspicion for TB, even in atypical presentations and immunocompetent individuals, is crucial, particularly in high-TB-burden regions. This case highlights the importance of considering disseminated extrapulmonary TB in the differential diagnosis, even in the absence of pulmonary involvement and typical risk factors. A high index of suspicion, a multidisciplinary approach, and a comprehensive diagnostic workup are essential for the timely recognition and management of these challenging conditions.

Radiomics features for the discrimination of tuberculomas from high grade gliomas and metastasis: a multimodal study.

BACKGROUND: Tuberculomas are prevalent in developing countries and demonstrate variable signals on MRI resulting in the overlap of the conventional imaging phenotype with other entities including glioma and brain metastasis. An accurate MRI diagnosis is important for the early institution of anti-tubercular therapy, decreased patient morbidity, mortality, and prevents unnecessary neurosurgical excision. This study aims to assess the potential of radiomics features of regular contrast images including T1W, T2W, T2W FLAIR, T1W post contrast images, and ADC maps, to differentiate between tuberculomas, high-grade-gliomas and metastasis, the commonest intra parenchymal mass lesions encountered in the clinical practice. METHODS: This retrospective study includes 185 subjects. Images were resampled, co-registered, skull-stripped, and zscore-normalized. Automated lesion segmentation was performed followed by radiomics feature extraction, train-test split, and features reduction. All machine learning algorithms that natively support multiclass classification were trained and assessed on features extracted from individual modalities as well as combined modalities. Model explainability of the best performing model was calculated using the summary plot obtained by SHAP values. RESULTS: Extra tree classifier trained on the features from ADC maps was the best classifier for the discrimination of tuberculoma from high-grade-glioma and metastasis with AUC-score of 0.96, accuracy-score of 0.923, Brier-score of 0.23. CONCLUSION: This study demonstrates that radiomics features are effective in discriminating between tuberculoma, metastasis, and high-grade-glioma with notable accuracy and AUC scores. Features extracted from the ADC maps surfaced as the most robust predictors of the target variable.

A Rare Case of Primary CNS Lymphoma in an HIV-Positive Patient Mimicking CNS Tuberculosis.

Primary cerebral lymphoma in immunocompromised patients is rare and challenging to diagnose. Its presentation can have similarities with other opportunistic diseases like cerebral toxoplasmosis and tuberculoma, to name a few, which may affect the subsequent management. Here, we report a case of a gentleman with human immunodeficiency virus (HIV) who presented with clinical features of fever, confusion, and generalized lethargy. His imaging features mimicked those of central nervous system (CNS) tuberculosis (TB), and he was treated for one. Unfortunately, the patient failed to respond to the anti-tuberculosis treatment and continued to deteriorate eventually succumbing to his illness. Brain histopathology biopsy confirmed the diagnosis of diffuse large B-cell lymphoma. We aim to illustrate the importance of a high index of suspicion with timely action taken whenever the anticipated finding or response to treatment is not observed. Multiple imaging modalities coupled with biochemistry and histopathological investigations should be considered in discriminating competing diagnoses.

Intracranial tuberculomas diagnosed with Xpert MTB/RIF Ultra assay of formalin-fixed paraffin-embedded brain tissues and treated with an optimized antituberculosis regimen: A case report.

Diagnosis of intracranial tuberculoma remains a challenge due to its rarity, non-specific clinical presentation, and radiological findings. Herein, we describe a case of intracranial tuberculomas in a male diabetic patient who presented headache and vomiting on admission. Neuroimaging findings indicated multiple ring contrast-enhanced lesions with extensive perilesional edema. However, a cerebrospinal fluid (CSF) examination was normal. When a biopsy of brain lesions was performed, pathological characteristics of tuberculosis were absent and acid-fast staining was negative. A tuberculosis diagnosis was subsequently obtained from an Xpert MTB/RIF Ultra assay of formalin-fixed paraffin-embedded brain tissue. The patient was treated with an optimized anti-tuberculosis regimen which included high-dose intravenous administration of rifampicin and isoniazid, and oral administration of linezolid. The patient recovered well and exhibited marked clinical improvement. This case report demonstrates that when CSF analysis does not indicate the presence of intracranial tuberculomas, analysis of formalin-fixed paraffin-embedded brain tissue specimens with the Xpert MTB/RIF Ultra assay may be able to confirm a diagnosis. Furthermore, a high dose of rifampicin and isoniazid plus linezolid may improve patient outcome.

The Role of Diffusion Tensor Imaging in CNS Tuberculosis.

Background and objective Tuberculosis (TB), caused by Mycobacterium tuberculosis, remains a significant global health concern, with India being a hotspot for the disease burden. Central nervous system (CNS) tuberculosis, though comprising a smaller proportion of total TB cases, is associated with significant morbidity and mortality. This study aimed to explore the utility of diffusion tensor imaging (DTI) in assessing the microstructural changes in white matter tracts associated with CNS tuberculosis. Materials and methods This study was conducted over two years at the All India Institute of Medical Sciences, Rishikesh. We employed a cross-sectional observational design and included patients with definite or highly probable tuberculous meningitis, alongside healthy controls. Results Our findings revealed a significant reduction in fractional anisotropy (FA) values in various white matter tracts of patients with CNS tuberculosis compared to healthy individuals. This reduction in FA correlated with the severity of tuberculous meningitis, particularly in the corpus callosum. Additionally, DTI highlighted distinct patterns of white matter involvement around intraparenchymal lesions, suggesting potential implications for clinical outcomes. The study emphasizes the utility of FA values in grading disease severity and prognosticating treatment outcomes in CNS tuberculosis. Conclusions Overall, this study provides valuable insights into the microstructural alterations in white matter tracts associated with CNS tuberculosis, highlighting the potential of DTI in early diagnosis, grading disease severity, and monitoring treatment response. We believe these findings will pave the way for further research to optimize the clinical management of this debilitating disease.

Numerous Asymptomatic Brain Tuberculomas Complicated by Fatal Tuberculous Meningitis.

Tuberculosis (TB) is still one of the most challenging infectious diseases worldwide. Coinfection with HIV increases the likelihood of extrapulmonary involvement, including the tuberculosis of the central nervous system (CNS-TB). CNS-TB often presents as tuberculomas or tuberculous meningitis. Although tuberculomas can be single or multiple, asymptomatic carriage of numerous tuberculomas is seldom reported. We present a case of a 55-year-old man who carried at least 34 tuberculomas of different sizes asymptomatically before developing and succumbing to tuberculous meningitis. Furthermore, we highlight several possible public health challenges that might have complicated his clinical course, suggesting that future studies also focus on these variables alongside more traditional clinical issues.

Analysis of the Diversity and Functional Potential of Bacterial Communities in Tuberculomas.

The dynamics of lung microbiota in tuberculosis remains poorly understood. Sequencing of variable regions of the 16S rRNA gene from surgically excised tuberculosis foci and biopsy specimens of normal lung tissue allowed characterization of the diversity and predictive potential of bacterial communities. Taxonomic diversity indices attested to differences in the structure of microbial communities between "healthy" lungs and tuberculomas. The microbial composition of "healthy" lungs varied in taxonomic diversity and was presented by both gram-positive and gram-negative bacteria with sufficiently similar metabolic potential. The microbiota of the examined tuberculomas consisted of Mycobacterium tuberculosis in 99.9% of cases. A significant part of the metabolic pathways predicted by PICRUSt2 included cholesterol catabolism, sulfate assimilation, and various pathways for the biosynthesis of cell wall components.

Multiple intracranial tuberculomas in an elderly patient: A central nervous system tuberculosis case in the emergency department.

A 67-year-old male presented to the emergency department with a 7-day history of fever, malaise, myalgia, headache, and a seizure episode. Physical examination showed stable vital signs but a fever. Laboratory tests indicated leukocytosis, anemia, thrombocytosis, and elevated inflammatory markers. Imaging revealed multiple intracranial lesions, and cerebrospinal fluid analysis confirmed the presence of acid-fast bacilli. The patient responded well to anti-tuberculosis therapy, showing significant clinical improvement within 8 weeks.

[Disseminated tuberculosis revealed by epididymal localization in an immunocompetent patient: a case report]. / Tuberculose disséminée révélée par une localisation épididymaire chez un patient immunocompétent: à propos d'un cas.

Epididymal tuberculosis is rare and often presents diagnostic difficulties. It may be indicative of a disseminated form of the infection, which is the case of our patient. A 19-year-old man, with no past medical history, was admitted for a swollen painful left scrotum that had been evolving for 8 months. He had undergone an orchiectomy and the anatomopathological examination was consistent with epididymal tuberculosis. The radiological investigations had revealed other localizations of the infection: lymphatic, pulmonary, parietal and osteoarticular tuberculosis. Anti-tuberculosis therapy was introduced. However, in the 4th month of treatment, the patient developed seizures. A cerebral magnetic resonance imaging was practiced, concluding to cerebral tuberculomas. Anti-tuberculosis treatment was continued associated to an anticonvulsant with a favourable outcome. The originality of our observation resides in the mode of revelation of a disseminated paucisymptomatic tuberculosis, by an epididymal localization, in an immunocompetent patient.

Outcomes of central nervous system tuberculosis in Saudi Arabia: a multi-center study.

OBJECTIVES: Central nervous system tuberculosis (TB) (CNS-TB) can occur in several forms, including intracranial tuberculoma, tuberculous brain abscess, TB meningitis (TBM), and spinal TB. Early treatment can save lives and prevent severe neurological complications. This study aimed to describe the characteristics and post-treatment outcomes of patients with CNS-TB and identify factors associated with poor outcomes. To the best of our knowledge, this is the largest CNS-TB study till date published in Saudi Arabia. METHODS: This retrospective cohort study included all patients diagnosed with CNS-TB in three tertiary centers in Saudi Arabia (King Abdulaziz Medical City in Jeddah, King Abdulaziz Medical City in Riyadh, and Al-Noor Specialist Hospital in Makkah) between 2009 and 2019. Data of patients' demographics, co-morbidities, presenting symptoms, type of CNS-TB, medical and surgical treatments, and outcome after completion of treatment were obtained from medical records. Treatment outcomes were categorized using the modified Rankin Scale for neurological disability. RESULTS: A total of 140 participants were included in this study from 2009 to 2019. Good outcomes were achieved in approximately 65% of cases, whereas 35% had poor outcomes based on the modified Rankin Scale. Glasgow Coma Scale score ≤10 at presentation and TBM/tuberculoma were significantly associated with poor outcomes. Moreover, the use of corticosteroids, more than three anti-TB medications, and surgical interventions were not significantly associated with good or poor outcomes. DISCUSSION: CNS-TB is associated with a high burden of long-term neurological morbidity. Early detection and treatment are crucial to prevent serious complications and decrease morbidity and mortality.

Tuberculoma Masquerading as a Sixth Cranial Nerve Palsy in a Young Patient: A Case Report.

Tuberculosis is a worldwide health concern with a wide range of clinical manifestations. Rarely, it can involve the central nervous system in the form of tuberculomas. Although cranial nerve palsies or localized neurological signs are the most frequent presentations of tuberculoma, isolated sixth nerve palsy is unusual and rare. We report the case of a 17-year-old female who presented with isolated sixth nerve palsy, an unusual early manifestation of intracranial tuberculoma. We established the diagnosis through clinical, radiological, and laboratory evaluations and successfully managed the patient with antitubercular therapy. This case highlights the importance of considering tuberculoma as a differential diagnosis in cases of isolated cranial nerve palsies, especially in regions with a high prevalence of tuberculosis.

Disseminated central nervous system tuberculoma in a patient with scrub typhus: A case report.

Central nervous system (CNS) tuberculosis mainly manifests as tuberculous meningitis and intracranial tuberculosis; intramedullary tuberculosis is uncommon. Scrub typhus is an acute naturally occurring infectious disease caused by Orientia tsutsugamushi. CNS tuberculoma following typhus is rare. The present study described a 60-year-old man with high fever, muscle soreness, yellowish skin and sclera and hepatosplenomegaly. At first, the patient was diagnosed with scrub typhus, after treatment with doxycycline he recovered completely. However, half a month after discharge, the patient experienced headache, night sweats and anorexia. Tuberculosis-specific enzyme-linked immunospot assay showed positive Mycobacterium tuberculosis antibody in cerebrospinal fluid (CSF). Metagenomic next-generation sequencing detected the presence of Mycobacterium tuberculosis in CSF. Magnetic resonance imaging of the brain and spinal cord showed multiple rings enhancing lesions in the cerebral hemispheres, cerebellum, brainstem and spinal cords. After the diagnosis of CNS tuberculoma, the patient was started on conventional anti-tuberculosis therapy resulting in a good prognosis.

Disseminated Tuberculosis of the Lungs, Brain, Pleurae, Mediastinal Lymphadenopathy, and Elbow Joint in an Immunocompetent Indian Female: A First-of-Its-Type Case.

Tuberculosis is usually seen in the lungs. However, the involvement of various extrapulmonary sites is due to the spread of the bacteria via blood, lymphatic, or direct inoculation. The present case is a rare presentation of tuberculosis in an Indian female who came with complaints of swelling in her right elbow joint, headache, and cough with expectoration. A diagnostic evaluation resulted in the isolation of Mycobacterium tuberculosis from the sputum samples and elbow joints, which was further supported by an exudative picture on the cerebrospinal fluid examination. The findings were supported by advanced radiometric techniques. She was commenced on an antituberculous treatment per her weight. Disseminated tuberculosis is a challenging diagnosis as there is often a delay in clinical presentation, a lack of awareness about the possibility of multiple sites with tuberculous infection in clinicians, and a time lag in the availability of the culture results.