# Persistent hydrocephalus following posterior fossa tuberculoma removal in pediatrics: A case report from a referral center in Indonesia

## TL;DR

This case report describes a 4-year-old child who developed persistent hydrocephalus after surgical removal of a posterior fossa tuberculoma, highlighting the challenges in diagnosing and managing CNS tuberculosis in pediatrics.

## Contribution

The paper presents a rare case of posterior fossa tuberculoma in a pediatric patient and discusses the complication of persistent hydrocephalus following surgery.

## Key findings

- Posterior fossa tuberculoma can lead to obstructive hydrocephalus requiring urgent surgical intervention.
- Persistent hydrocephalus after tuberculoma removal may indicate underlying tuberculous meningoencephalitis.
- Early diagnosis and monitoring are crucial for managing CNS tuberculoma in children.

## Abstract

The threat posed by tuberculosis persists in developing countries. Individuals under the age of five were more likely to develop central nervous system (CNS) tuberculosis. CNS Tuberculoma of the posterior fossa has rarely been reported, and its consequences are more devastating due to the limited space of the posterior fossa.

A 4-year old male was referred to our academic general hospital with main complaint of decreased consciousness for the last 3 days. The patient has experienced a low-grade fever, cough, and an enlarging neck tumor for two months. Any contact with confirmed tuberculosis patients was denied by the family. A suspected cerebellar abscess and obstructive hydrocephalus led to the patient's referral. Urgent evacuation of the posterior fossa mass was conducted, revealing a histopathological diagnosis of tuberculoma. After the procedure, the patient experienced seizures and no improvement of GCS. A head CT scan evaluation revealed a communicating hydrocephalus. A ventriculoperitoneal shunt is done, resulting in improvement of the patient's consciousness after CSF diversion.

The haematogenous spread of Mycobacterium, which causes granulomatous foci in the brain, is the cause of CNS tuberculoma. The neuroradiological characteristic of tuberculomas may mimic several conditions. Thorough history-taking and physical examination may lead to a focused differential diagnosis of the patient. Evacuated posterior fossa tuberculoma usually leads to resolved obstructing hydrocephalus. A persistent hydrocephalus leads to the possibility of communicating hydrocephalus due to tuberculous meningoencephalitis. Close monitoring following excision of posterior fossa tuberculoma may help identify persistent hydrocephalus early on.

CNS tuberculoma should remain a differential diagnosis of ring-enhancing posterior fossa mass, especially in pediatrics. This condition may present concomitantly with tuberculous meningoencephalitis, and it may be presented as a persistent hydrocephalus following the surgical removal of the lesion.

•Diagnosing CNS Tuberculoma is a challenge in pediatrics, since the clinical presentation may be atypical and the radiologic presentation may mimic other conditions.•CNS Tuberculoma of the posterior fossa that leads to obstructive hydrocephalus should be evacuated as soon as possible due to the limited space of the posterior fossa.•Removal of the obstructing mass should lead to resolve hydrocephalus; however, persistence of hydrocephalus should prompt clinician for the possibility of tuberculous meningoencephalitis.

Diagnosing CNS Tuberculoma is a challenge in pediatrics, since the clinical presentation may be atypical and the radiologic presentation may mimic other conditions.

CNS Tuberculoma of the posterior fossa that leads to obstructive hydrocephalus should be evacuated as soon as possible due to the limited space of the posterior fossa.

Removal of the obstructing mass should lead to resolve hydrocephalus; however, persistence of hydrocephalus should prompt clinician for the possibility of tuberculous meningoencephalitis.