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| IMAGES IN RADIOLOGY |
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| Year : 2002 | Volume
: 48
| Issue : 1 | Page : 54-5 |
Intramedullary tuberculoma of the spinal cord.
A Arslantas, A Faruk, B Kismet, T Esref
Departments of Neurosurgery and Pathology, The University of Osmangazi, and Department of Neurosurgery, Social Security Hospital, Eskiehir, Turkey. , Turkey
Correspondence Address:
A Arslantas
Departments of Neurosurgery and Pathology, The University of Osmangazi, and Department of Neurosurgery, Social Security Hospital, Eskiehir, Turkey.
Turkey
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 12082333 
Keywords: Adult, Case Report, Cerebrospinal Fluid, chemistry,Human, Magnetic Resonance Imaging, Male, Thoracic Vertebrae, pathology,Tuberculosis, Spinal, diagnosis,therapy,
How to cite this article:
Arslantas A, Faruk A, Kismet B, Esref T. Intramedullary tuberculoma of the spinal cord. J Postgrad Med 2002;48:54 |
A 36-year-old man presented with the complaints ofintermittent fever and paroxysms of dyspnoea. His chestX-ray film revealed apical changes of the right lung and diffuse interstitial infiltration. The condition was diagnosed as pulmonary tuberculosis and a course of quadruple chemotherapy was begun. Three months after discharge, the patient was referred to the neurosurgery clinic with the complaints of lower back pain, bilateral leg pain and weakness. Neurological examination revealed paraplegia, urinary incontinence and spastic reflexes. Thoracic, cervical and lumbar X-rays were normal. Thoracic spinal magnetic resonance imaging (MRI) revealed a circumscribed intramedullary mass at the level of tenth thoracic vertebrae with a hyperintense ring enhancement of the pia-arachnoid involving the whole of the dorsal cord [Figures]. The lesion was diagnosed as intramedullary mass and high-dose steroids were consequently added to the anti-tuberculosis therapy. Cerebral computed tomography was normal.
Biochemical analysis of the cerebrospinal fluid revealed an elevated protein level of 85mg/dl, a glucose level of 14.1 mg/dl, 25% polymorphonuclear leukocytes, and 75% monocytes. Blood glucose level was 130 mgr/dl. Cerebrospinal fluid culture was negative. HbSAg, H1V, HCV testes were negative. Because of the progressive deterioration of neurological status, surgical resection of the lesion was performed; followed by posterior longitudinal myelotomy was executed and gray mass excised. Histopathological examination of the mass revealed a granulomatous lesion containing Langhans-type giant cells and lymphocytes, leading to a diagnosis of intramedullary spinal tuberculosis. The patient showed no new neurological deficit postoperatively, and at the time of this report he was undergoing a rehabilitation program.
Central nervous system involvement of tuberculosis is rare compared with other systems involvement. Intramedullary tuberculomas (IMT) are seen in only 2 out of 100,000 cases of tuberculosis and 2 out of 1,000 cases of central nervous system tuberculosis.[1],[2] Cord compression from tuberculosis is usually due to vertebral involvement (Pott disease). In addition to extradural lesions, intradural and intramedullary involvement may also occur. Dastur reviewed 74 cases of tuberculosis paraplegia without evidence of Pott’s disease and discovered that extradural granulomas occurred at a rate of 64%, arachnoidal lesions at a rate of 20%, intramedullary lesions at a rate of 8%, and subdural extramedullary lesions at a rate of 1%.[3]
Recent case reports have presented intramedullary tuberculoma found in patients with HIV,[4] auto-immune disease, especially systemic lupus erythematosus[5] and patients undergoing immunosupressive treatment due to liver transplantation.[6]
Intramedullary tuberculomas occur usually in young people and usually in the thoracic spinal cord.[2] Although it frequently presents signs of subacute spinal cord compression, variable clinical presentations with Brown-Sequard syndrome and episodes of paraplegia have also been reported.[1],[5]
The magnetic resonance imaging appearance of IMT are characterised by hypointense ring enhancement, with or without central hyperintensity (reflecting caseating necrosis) on T2 images and hypo to isointense rings on Tl images.[7]
Although it has been proven that IMT can recover totally with chemotherapy alone, a paper has been presented on micro-surgical resection associated with chemotherapy,[8] and Mac Donnel has reported 65% recovery after surgical resection.[2] However, neurological deficit, occurring despite sufficient chemotherapy, has also been reported.[1] Due to the increase both in AIDS patients and patients on successful immunosuppressive therapies, IMTs are likely to increase, not only in developing countries but also in developed countries. Having so important a place, then, in the diagnosis of subacute spinal cord compression cases, this problem needs to be taken into consideration. Even when anti-tuberculosis treatment has been started in the early phases of pulmonary tuberculosis, neurological deficits may develop in the patient in spite of effective chemotherapy; in such a case IMT should be considered immediately. Since IMT may develop during chemotherapy and the surgical treatment of it yields good results on patients diagnosed in the early phases, spinal and cerebral MRI studies should be done on patients who have been treated with chemotherapy for pulmonary tuberculosis.
| :: References | |  |
| 1. | Citow JS, Ammirati M. Intramedullary tuberculoma of the spinal cord: Case report. Neurosurgery 1994;35:327-30.  |
| 2. | MacDonnell AH, Baird RW, Bronze MS. Intramedullary tuberculomas of the spinal cord: case report and review. Rev Infect Dis 1990; 12:432-9. |
| 3. | Dastur HM. Diagnosis and neurosurgical treatment of tuberculous disease of the CNS. Neurosurg Rev 1983;6:111-7. |
| 4. | Borges MA, Carmo MI, Sambo MR, Borges FC, Araujo CM, Campos MJ, et al. Intramedullary tuberculoma in a patient with human immunodeficiency virus infection and disseminated multidrug-resistant tuberculosis: case report. Int J Infect Dis 1998;2:164-7. |
| 5. | Kirn WU, Lee SH, Shim BY, Min JK, Hong YS, Park SH, et al. Intramedullary tuberculosis manifested as Brown-Sequard syndrome in a patient with systemic lupus erythematosus. Lupus 2000;9:147-50. |
| 6. | Revald P, Olsen BS, Gronbaek H, Duel P. Intramedullary tuberculous abscess in a patient with liver transplantation. Ugeskr Laeger 2000;162:502-3. |
| 7. | Jena A, Banerji AK, Tripathi RP, Gulati PK, Jain RK, Khushu S, et al. Demonstration of intrameduilary tuberculomas by magnetic resonance imaging: a report of two cases. Br J Radiol. 1991;64:555-7. |
| 8. | Kayaoglu CR, Tuzun Y, Boga Z, Erdogan F, Gorguner M, Aydm IH. Intramedullary Spinal tuberculoma. Spine 2000;25:2265-8. |
Figures
[Figure - 1], [Figure - 2]
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