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Brain Tuberculomas: A Case Report

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DOI: 10.5812/jjm.11252 · Source: PubMed

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Jundishapur J Microbiol. 2014 July; 7(7): e11252. DOI: 10.5812/jjm.11252
Published online 2014 July 1. Case Report

Brain Tuberculomas: A Case Report

1,2,* 3 1
Maryam Saleh ; Ali Asghar Saeedi ; Ali Ali Pooran
1Department of Infectious Diseases, Sajad Hospital, Tehran University of Medical Sciences, Tehran, IR Iran
2Influenza Research Center, Pasteur Institute of Iran, Tehran, IR Iran
3Department of Infectious Diseases, Besat Hospital,Tehran University of Medical Sciences, Tehran, IR Iran

*Corresponding author: Maryam Saleh, Department of Infectious Diseases, Sajad Hospital, Influenza Research Center, Pasteur Institute of Iran, 12th Farvardin Street, Enqelab Avenue,
1316943551, Tehran, IR Iran. Tel: +98-9125442748, Fax: +98-2166496517, E-mail: health.mic@gmail.com-marysa@pasteur.ac.ir

Received: April 6, 2013; Revised: June 1, 2013; Accepted: June 16, 2013

Introduction: An unusual incidence of tuberculosis in different parts of the body is called tuberculomas. The rate of brain tuberculosis
is rare.
Case Presentation: The following case of tuberculamas of the brain, presented by enhancing rings of meninges, is reported because of
its rarity. It was a case of brain tuberculomas in a 15-year-old girl with primary symptoms of headache and general weakness, and no signs
of primary pulmonary infection.
Discussion: The subject underwent computerized tomography (CT) and magnetic resonance imaging (MRI) of the brain. Microbiological
tests (acid fast bacilli smear-AFB, and culture of biopsy specimen) were applied subsequently. According to the results, the problem was
diagnosed as brain tuberculomas. After operation she was completely treated with anti-TB drugs. Although brain tuberculosis is rare, it
was diagnosed on the basis of histopathology and the patient's successful response to anti-tuberculous drug treatment.

Keywords:Mycobacterium tuberculosis; Tuberculoma; Brain

1. Introduction
Tuberculosis (TB) is a multi-systemic infectious disease infection) was referred to the emergency room of Sajad
caused by different species of mycobacteria, usually My- Hospital. She was the first child of acouple with no fam-
cobacterium tuberculosis in humans (1). Tuberculosis of ily relationship. She was studying in a high school with
the nervous system can attack the meninges, brain, spi- low level of sociocultural state in North of Iran. Her fam-
nal cord, cranial and peripheral nerves, ears, and eyes. ily did not have any symptoms of tuberculosis. There was
Brain tuberculosis results from spreading the bacteria a history of general weakness in the recent six months
which primarily exists in the body. A study conducted in with internal work up and progression to neurological
Chile reported only one case of multiple lesions among deficit. She could not move her right side of the body but
five cases and then also recorded 33 cases of multiple she responded to questions on and off and obeyed the
tuberculomas out of 97 verified cases (2). Even in the orders. She could respond to medical interrogation. She
countries where tuberculosis is common, few cases of was oriented in time, place and person. Paresthesia of left
tuberculous brain abscess have been reported. The cur- extremities and neck problem was found. Cranial nerves,
rent study showed a definite preoperative diagnosis with sensory and motor-systems were normal with no signs of
histological examination and radiographic findings; per- meningeal irritation. Skull X-ray revealed normal.
haps misdiagnosed may occur without all the findings Paraclinical and physical examinations such as Chest X-
together and it could be considered as a dilemma. Due to ray, brain Computerized Tomography (CT) Scan, abdom-
the possibility of concurrent infections and responsible ino pelvic CT scan and brain Magnetic Resonance Imag-
microorganisms, it is important to evaluate all the pos- ing (MRI) were applied. Microscopic examination (direct
sible related causes of the infectious diseases. examination) of a biopsy specimen was also performed.
The primary diagnosis was herpes with differential di-

2. Case Presentation
agnosis due to involvement of parieto-temporal lobe in
her CT scan. She received acyclovir and was admitted in
In 2009, a 15-year-old girl with altered consciousness, infectious disease ward. The patient did not respond to
drowsiness and abnormality in gait motor and sensa- the treatment. Multislice helical CT scan of chest, with
tion of left side extremities (with no signs of pulmonary and without contrast media, showed extensive cavitary

Implication for health policy/practice/research/medical education:

The current article reports one of the most important or the first reported cases of Mycobacterium tuberculosis as the causative agent of brain tuberculosis
infection in Iran. It was a rare case and would help to recognize cases that can be applied to better diagnostic aspects against infectious diseases caused
by M. tuberculosis.
Copyright © 2014, Ahvaz Jundishapur University of Medical Sciences; Published by Kowsar Corp. This is an open-access article distributed under the terms of the Cre-
ative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
 Saleh M et al.

consolidation at left upper lobe. Peribroncho vascular

nodular infiltration with tree-in-bud appearance was
noted at posterior and apical segments of upper and low-
er lobes. Pleural effusion was not observed. Mediastinal
adenopathies were present in prevascular, paratracheal
and azygoesophageal recess distributions. Multisliceheli-
cal CT-scan of abdominopelvic with and without contrast
media found mild ascites around the liver and pelvic cav-
ity. Multiple hypodense lesions in favor of adenopathies
were noted at portahepatis celiac chain, retrocaval and
precaval levels. Mild dilatation was visualized at both pel-
vicalyceal systems.
Figure 1. The magnetic resonance image of the brain showing enhanc-
Histological studies demonstrated no primary focus in ing nodules in deep white matter and subcortical area in the right fronto-
the lungs. Cavitation and tree-in-bud were observed in parieto-temporal region and also left cerebellar hemisphere showing foci
CT scan of lungs. Axial CT scan of the brain demonstrat- of hemorrhage with surrounding edema and mass effect and irregularity
ed large hypodensity area and ring-enhancing lesion in ring enhancement

right middle cerebral artery territory with some hemor-

rhagic area. Edema in right hemisphere and compres-
sion on right lateral ventricle and some midline shift
to left were noted. Hypodensity area in left cerebellum
was observed too. All of the symptoms were compatible
with those of ischemic hemorrhage or metastatic hem-
orrhage. The grate cerebral vein and the venous sinuses
had normal caliber in Magnetic Resonance Venography
(MRV). Other Organs such as liver, spleen, kidneys, gall-
bladder and uterus were normal.
Magnetic resonance imaging (MRI) examination of the
brain was performed with intravenous contrast, and uti-
lizing axial T1-weighted sequences. There were multiple
T1 low signal masses in the right fronot-parie to-temporal
region and also left cerebellar hemisphere showing foci
of hemorrhage with surrounding edema and mass effect
and irregularity ring enhancement. No other abnormali-
ties were observed (Figure 1).
brain MRI with and without gadolinium (GD) injection
determined post-op changes with mass effect and hem-
orrhage in the right-fronto-parietal and left cerebellar
hemisphere. No abnormal enhancement was reported
after contrast injection. Air fluid level was observed in
the right maxillary sinus. No other abnormalities were Figure 2. Brain MRI illustrates a separate circular mass at the top of fron-
observed (Figure 2). In the physical exam, ill-defined bor- tal region with hemorrhage in the right fronto-parietal and left cerebellar
hemisphere and air fluid level in right maxillary sinus
ders were pale.
Microscopic examination: The most sensitive tests, acid

3. Discussion
fast bacilli smear (AFB) and culture of a biopsy specimen,
were performed. Puncturing viscous fluid material was
taken, smears were made and stained with acid-fast stain Tuberculosis is still a leading cause of death among the
and a number of acid-fast bacilli were observed (4+). infectious diseases. Because of the current migratory
Treatment and drugs: Antibiotics: ciprofloxacin (500- patterns, tuberculosis has become a global concern and
750ng), ethambotol (800 ng), isoniazid (300 ng) and early diagnosis of active Tuberculosis is vital for its treat-
omeprazole (20 mg) were prescribed. ment. The World Health Organization (WHO) declared
Surgery: For patients with neurological deficits, surgi- tuberculosis as a global emergency in 1993. Provisional
cal intervention is recommended (3, 4). The patient un- data from Health Protection Agency UK (HPA) showed
derwent the brain surgery. Multiple sections were taken that 8587 cases of tuberculosis were reported in the UK
and studied in detail histologically. Pathological right in 2010. This is a rate of 13.9 per 100000 population. In
frontal lesion specimen of the brain showed extensive 2008, 334 patients died from tuberculosis which is 0.6
areas of caseating like necrosis suggesting histological per 100000 population. These data are significantly bet-
diagnosis of tuberculomas. ter, compared those of1955 in which 3900 patients died

2 Jundishapur J Microbiol. 2014;7(7):e11252

 Saleh M et al.

from tuberculosis with mortality rate of 8.8 per 100000 ery on anti- tuberculosis treatment as the last treatment.
population (5). In 2012 report of a case presented with The frequency of brain tuberculosis depends on the site
prolonged nonspecific symptoms and multiple brain tu- involved. Possible side effects of anti-TB drugs of patients
berculomas demonstrated that diagnosis of such pecu- should be clinically evaluated at least monthly. Patients
liar presentations is very important (6). usually do not need the follow-up after completion of
Brain abscesses are tuberculomas that develop into pus- therapy if signs or symptoms do not recur. In the current
filled cavities and indicate poor defense mechanisms. study the patient was followed up for three years, and
They are rare and may require surgical excision (7). Tuber- CT after one year showed complete disappearance of all
culomas constitute 33% of intracranial space-occupying tuberculomas. Microscopic examination and mycobacte-
lesions in patients in developing countries (8). Calcifica- rial culture fitted into her recovery as well.
tion may be present within the contrast enhanced ring,
creating a target sign which is probably a sign of reacti- Acknowledgements
vation (9). Brain tuberculomas is rare and its diagnosis
The authors acknowledge their gratitude to all the col-
would be difficult and impossible because of its variety of
leagues of Sajad Hospital Microbiology, laboratory and
presentation, therefore clinical findings and special tests
Radiology departments, Tehran, Iran.
are needed. CT was reported to have a sensitivity of 100%
and specificity of 85.7% thus it indicated a need for further
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