Disseminated Tuberculosis Revealed by Conus Medullaris Tuberculoma.

A 29-year-old man from Comoros presented with rapidly progressive paraplegia and sexual dysfunction. Magnetic resonance imaging (MRI) showed a contrast-enhanced conus medullaris lesion. Differential diagnoses included tumors, abscesses, and inflammatory diseases. Neurosurgery was delayed to complete examinations. Cerebral MRI showed three abscesses. Body computed tomography scan showed supracentimetric polyadenopathies, pulmonary nodules, prostatic lesion, and enhanced seminal vesicle, with hypermetabolism on positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose scan. Histology of lymph node biopsy showed granulomatous infiltration without acid-fast bacilli, and positive polymerase chain reaction for Mycobacterium tuberculosis. Lymph node culture was positive after 2 months, urine culture after 3 weeks, but cerebrospinal fluid and sputum cultures were negative. A 1-year antituberculosis therapy was initiated, associated with corticosteroids because the patient developed tuberculosis-immune reconstitution syndrome, revealed by the recurrence of neurological symptoms. After 2 months the patient completely recovered and could run. MRI showed stability of the voluminous tuberculoma with decrease of medullary edema. Avoiding surgery in those cases may prevent iatrogenic neurological deterioration.

Unilateral solitary choroidal tuberculoma as the presenting sign in disseminated tuberculosis in an immunocompetent patient.

INTRODUCTION: Tuberculosis can involve any organ in the body including ocular tissue of which the uveal tissue is most commonly infected. Choroidal involvement ranges from choroidal tubercles to granulomas. This is one of the few cases of a solitary choroidal granuloma with no other systemic symptoms in an immunocompetent child. METHOD: A case report. RESULTS: A 12-year-old female, presented with diminution of vision in the left eye for a month. The anterior segment of her left eye was normal. A fundus examination revealed an isolated orangish-yellow choroidal mass, 4 DD in size, involving the posterior pole with overlying subretinal exudation. CT scan of the thorax showed large pulmonary, cervical and pancreatic lymph nodes, along with lytic lesions of the thoracic vertebrae. Excision biopsy of the cervical lymph nodes showed caseating granulomas with no e/o malignancies on histopathology. The patient was started on anti-tubercular therapy. Six months after the treatment, the lesion had reduced in size and her vision had improved. CONCLUSION: Isolated choroidal tuberculomas can be present in eyes with little associated ocular inflammation and no other symptoms of systemic tuberculosis. High suspicion, early diagnosis and rapid initiation of medication are important for the treatment of ocular and systemic tuberculosis.

Tuberculoma - a great mimicker: can diffusion tensor imaging and tractography help?

BACKGROUND: Central nervous system (CNS) tuberculomas often mimic tumors on conventional imaging, differentiation of which may not be possible without invasive tissue sampling. Diffusion tensor imaging (DTI), owing to its unrivalled property of characterizing molecular diffusion, may help in better lesion characterization and tractography may help understand the pattern of white matter involvement by tuberculomas. PURPOSE: To estimate qualitative and quantitative diffusion tensor changes in brain tuberculomas and to evaluate patterns of white matter involvement using 3D tractography. MATERIAL AND METHODS: Thirty patients with brain tuberculomas were evaluated on a 3-T magnetic resonance scanner. Diffusion tensor images were acquired along 20 non-colinear encoding directions with two b-values (b = 0, b = 1000). Regions of interest (ROIs) were drawn on quantitative fractional anisotropy (FA) and apparent diffusion coefficient (ADC) maps in the center of the tuberculoma and perilesional area. Similar ROIs were placed in contralateral hemispheres for comparison. Tractography maps were also generated. RESULTS: Mean FA in the center and perilesional area of tuberculomas were 0.098 ± 0.041 and 0.311 ± 0.135, respectively. ADC values in corresponding regions were 0.920 ± 0.272 ×10-3 mm2/s and 1.157 ± 0.277 ×10-3 mm2/s. These values were significantly different compared to contralateral similar brain parenchyma. Tractography revealed interruption of white fibers in the center with deviation of fibers at the periphery in the majority of tuberculomas with none showing infiltration of white matter described in tumors. CONCLUSION: Significant qualitative as well as quantitative DTI changes were seen in tuberculoma and perilesional areas compared to contralateral hemisphere with tractography showing a pattern different from that described in tumors. These findings may help to differentiate tuberculomas from infiltrating tumors.

Tumour-like presentation of brainstem tuberculoma: a lesson learnt.

Brainstem tuberculoma is diagnostically challenging as it lacks clinical clues and imaging mimics a high-grade glioma (HGG). We report the case of an adolescent girl diagnosed with brainstem HGG, who was referred to our centre for Gamma Knife. Initial MRI showed a pontomedullary junction, ring-enhancing lobulated lesion demonstrating distinct central hypointensity on T2-weighted (T2W) and fluid-attenuated inversion recovery (FLAIR) images with extensive vasogenic oedema. An alternative diagnosis of infection was entertained, and biopsy was suggested; however, the parents opted for a trial of alternative treatment. Suboccipital craniotomy and debulking were only performed 3 months later when her symptoms worsened, and MRI revealed enlargement of the lesion. A cheesy 'tumour' was noted intraoperatively; histopathological findings later confirmed chronic granulomatous inflammation. In an endemic area, a high index of suspicion of a tuberculoma is vital specifically in the presence of central T2W/FLAIR hypointensity of a ring-enhancing lesion.

Giant cerebral tuberculoma mimicking a high-grade tumour in a child.

We present an 11-year-old girl who manifested with unprovoked right-sided focal motor seizures. CT revealed a large lobulated hypodense mass in the left temporoparietal lobe, with perilesional oedema and postcontrast peripheral enhancement. Diagnostic uncertainty resulted in further neuroimaging, which included MRI with modalities including diffusion-weighted imaging, perfusion imaging, as well as spectroscopy. We discuss the radiological features of the lesion, which steered us in the direction of an infective cause. Definitive diagnosis was achieved by brain needle biopsy, which demonstrated necrotising granulomatous inflammation indicative of tuberculous infection on histology. In addition, GeneXpert yielded a positive result. We believe this unique case highlights the diagnostic dilemma clinicians face in differentiating ring-enhancing lesions on neuroimaging in tuberculosis-endemic regions. It also highlights the potential benefit of a brain needle biopsy (histology and GeneXpert) in cases of uncertainty.

Intradural extramedullary tuberculoma of the spinal cord mimicking meningioma.

Intradural extramedullary tuberculoma of the spinal cord is an extremely rare central nervous system tuberculosis manifestation. It is even rarer in patients who have no history of primary tuberculosis. A total of five cases, including the present case of intradural extramedullary tuberculoma without a history of primary tuberculosis, have been reported in the literature. We report a case of a male patient in his 20s who came with progressive weakness in his lower limbs, urinary incontinence and MRI features suggestive of meningioma. The patient underwent a D9-11 laminectomy with total debulking of the tumour. The histopathological examination revealed Langhans-type giant cells, confirming the diagnosis of a tuberculoma. The patient was advised an antitubercular therapy for 18 months. On a follow-up after 1 month, the patient could walk without support and had no urinary incontinence, indicating the importance of prompt surgical resection and adequate antitubercular therapy for a better outcome.

MULTIMODAL IMAGING OF AN INTRARETINAL TUBERCULAR GRANULOMATOUS NEURORETINITIS.

PURPOSE: To report a rare case of an intraretinal tuberculoma and associated neuroretinitis. METHODS: The patient was evaluated with various imaging modalities including fundus photography, fluorescein angiography, magnetic resonance imaging, and optical coherence tomography; her extensive laboratory workup returned positive for tuberculosis. RESULTS: After initially presenting with no light perception, 13 weeks of antitubercular therapy allowed for visual acuity recovery to 20/30. CONCLUSION: We demonstrate the spectral domain optical coherence tomography characteristics of an intraretinal tuberculoma.

Intractable singultus as an initial symptom of medulla oblongata tuberculoma: A rare case report.

Tuberculoma of medulla oblongata is a rare manifestation of central nervous system tuberculosis (CNS TB), which may manifest as intractable singultus as the initial symptom. It is almost impossible to obtain definite diagnosis through biopsy consider its location. Immediate thorough diagnostic workup is needed, and empirical treatment should be started. We report a case of medulla oblongata tuberculoma in an HIV-negative 38-year-old man with intractable singultus as one of the early symptoms. He was treated empirically with anti-tuberculosis therapy and his symptoms subsided within 2 weeks.

[A Case of Cerebral Tuberculoma].

Cerebral tuberculoma is a rare and serious form of tuberculosis. Despite advancements in imaging and laboratory diagnostics, it is challenging to diagnose cerebral tuberculoma due to its insidious nature and nonspecific findings. A 56-year-old woman was referred to our hospital for headaches. The patient had previously undergone treatment for pulmonary tuberculosis, which had been completely cured 2 months prior to presentation. Brain MRI revealed an enhanced mass lesion with surrounding edema in the right frontal lobe. Although a mild increase in the serum carcinoembryonic antigen(CEA)level and a moderate accumulation of FDG on FDG-PET indicated inflammatory changes or a malignant brain tumor, other imaging and laboratory findings were nonspecific. The mass lesion was indistinguishable from a brain tumor. Hence, the patient underwent surgical removal, and the pathological diagnosis was tuberculoma. In patients with a history of tuberculosis, cerebral tuberculoma should be considered in the differential diagnosis of intracranial mass lesions, even if the original lesion is completely cured. A mild increase in the serum CEA level and a moderate accumulation of FDG on FDG-PET were considered indicative of intracranial inflammation and consistent with cerebral tuberculoma.

Combination of CT and telomerase+ circulating tumor cells improves diagnosis of small pulmonary nodules.

BACKGROUNDEarly diagnosis and treatment are key to the long-term survival of lung cancer patients. Although CT has significantly contributed to the early diagnosis of lung cancer, there are still consequences of excessive or delayed treatment. By improving the sensitivity and specificity of circulating tumor cell (CTC) detection, a solution was proposed for differentiating benign from malignant pulmonary nodules.METHODSIn this study, we used telomerase reverse transcriptase-based (TERT-based) CTC detection (TBCD) to distinguish benign from malignant pulmonary nodules < 2 cm and compared this method with the pathological diagnosis as the gold standard. FlowSight and FISH were used to confirm the CTCs detected by TBCD.RESULTSOur results suggest that CTCs based on TBCD can be used as independent biomarkers to distinguish benign from malignant nodules and are significantly superior to serum tumor markers. When the detection threshold was 1, the detection sensitivity and specificity of CTC diagnosis were 0.854 and 0.839, respectively. For pulmonary nodules ≤ 1 cm and 1-2 cm, the sensitivity and specificity of CTCs were both higher than 77%. Additionally, the diagnostic ability of CTC-assisted CT was compared by CT detection. The results show that CT combined with CTCs could significantly improve the differentiation ability of benign and malignant nodules in lung nodules < 2 cm and that the sensitivity and specificity could reach 0.899 and 0.839, respectively.CONCLUSIONTBCD can effectively diagnose pulmonary nodules and be used as an effective auxiliary diagnostic scheme for CT diagnosis.FUNDINGNational Key Research and Development Project grant nos. 2019YFC1315700 and 2017YFC1308702, CAMS Initiative for Innovative Medicine grant no. 2017-I2M-1-005, and National Natural Science Foundation of China grant no. 81472013.

Giant central nervous system tuberculoma in pediatric patients: surgical case series.

Central nervous system tuberculoma is rare and challenging situation. Clinical records of patients with pathologically proven tuberculoma were retrospectively reviewed. Clinical presentation, lesion location, radiological characteristics, perioperative and surgical management, and outcome is summarized and analyzed. Eight patients were included and there was one girl. Age ranged from 3 to 14 years with mean age 9.8 years. Clinical duration ranged from 20 days to 2 years, and 3 patients had previous lung tuberculosis with anti-TB treatment. The lesion was in cerebellum in 6 cases, including 1 involving basal ganglia and 1 involving thalamus. The lesion was in basal ganglia, thalamus, and third ventricle in 1 case, and in T12-L1 spinal cord in another. Cerebellar lesion was resected via paramedian suboccipital approach in 5 patients, basal ganglia lesion via trans-cortical frontal horn approach in 2 patients, and intra-spinal lesion via trans-laminar approach in 1 patient. Follow-up ranged from 10 to 24 months. Of the 8 patients, 6 returned to normal life. One patient had cerebellar lesion resected and the thalamic lesion reduced in size after anti-TB treatment. One patient died from TB spreading. Our data showed that most patients can be successfully treated by resection of the lesion. Low T2 signal, ring shaped enhancement and peripheral edema strongly suggest tuberculoma. Empirical anti-TB treatment should be initiated perioperatively.