Unusual clinical presentation of tuberculoma

R Verma, P Sharma 
 Department of Neurology, Chhatrapati Shahuji Maharaj Medical University, Lucknow, U.P., India

Correspondence Address:
R Verma
Department of Neurology, Chhatrapati Shahuji Maharaj Medical University, Lucknow, U.P.
India

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A 24-year-old gentleman presented acutely with gait disturbances, nausea, vomiting, and dizziness. He was also complaining of dysphagia, dysarthria, and decreased sweating on right half of face. Detailed neurological examination revealed right-sided Horner syndrome, horizontal nystagmus with torsional component beating toward left, right 9 th , and 10 th cranial nerve palsy, gait ataxia with swaying toward right side along with impairment of thermal, and pain sensation over the right face and left side of the body. Suspecting an acute ischemic event involving posterior circulation, a magnetic resonance imaging (MRI) was performed which showed a ring-enhancing intra-axial lesion in right medulla oblongata. The lesion was showing hyperintense signals on T1 contrast and FLAIR images with surrounding edema [Figure 1] and [Figure 2]. No apparent restriction of diffusion was present and magnetic resonance angiography was also normal. To ascertain the nature of the lesion, cerebrospinal fluid (CSF) examination was done which yielded 28 cells/mm 3 of lymphocytes, 56 mg% of protein, and 32 mg% of glucose. CSF culture and CSF polymerase chain reaction (PCR) were positive for Mycobacterium tuberculosis. India ink preparation and Elisa test for neurocysticercosis were negative in CSF. Thus, a tubercular etiology was established and a diagnosis of brain stem tuberculoma presenting as lateral medullary syndrome was considered. He was treated with standard four drug antitubercular regimen with corticosteroids. He showed good response to the treatment, and repeat MRI after one month of treatment showed regression of lesion [Figure 3] and [Figure 4]. He was almost asymptomatic at one-year follow-up and the lesion was remarkably reduced in size with atrophy of surrounding medulla in repeat MRI after one year [Figure 5].{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}

Lateral medullary syndrome is characterized by a constellation of neurological symptoms and signs due to injury of lateral part of the medulla. Most commonly, it results from a vascular insult secondary to vertebral artery or posterior inferior cerebellar artery occlusion. The critical location of the lesion in right lower medulla in our patient explains all the clinical manifestations. Positive CSF culture and PCR for mycobacteria, characteristic neuroimaging finding, and response to antitubercular treatment supported the diagnosis of tuberculoma. The main clinical and radiological differential diagnosis is given in [Table 1]. MRI characteristics of intracranial tuberculoma are extremely diverse. The MR features of the individual tuberculoma depend on presence of caseation in the granuloma. A hypointense core with a hyperintense rim was the most common signal characteristic on T2-weighted MRI. The central hypointensity on T2-weighted and FLAIR images reflect widespread necrosis and hypercellularity. [1] Many clinical syndromes depending upon site of intracranial tuberculoma are reported in the literature. Kumar et al. reported a patient presenting as isolated bilateral ptosis due to midbrain tuberculoma. [2] Pontine tuberculoma presenting as horizontal gaze palsy is also described [3] To the best of our knowledge, lateral medullary syndrome due to brainstem tuberculoma has not been previously reported. We conclude that tuberculoma should be considered as an etiology in brainstem space-occupying lesions presenting as lateral medullary syndrome, particularly in developing countries.{Table 1}

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