Intracranial Tuberculomas Associated with Tuberculous Meningitis

Abstract

Figures

Full text

A 58-year-old woman presented to the emergency department with fever, impaired consciousness, and seizures. Quadruple antituberculosis therapy for pulmonary tuberculosis was commenced and continued for one month. Physical examination revealed a fever of 37.7°C and stiffness of the neck. The C-reactive protein (CRP) levels (17.5 mg/L) and erythrocyte sedimentation rate (48 mm/h) were elevated; however, the remaining parameters were within normal limits. Previous sputum cultures confirmed the presence of Mycobacterium tuberculosis. Noncontrast computed tomography (CT) of the brain and magnetic resonance imaging (MRI) revealed white matter edema (Figure 1). Contrast-enhanced MRI revealed peripheral enhancement of the abscess foci (tuberculomas) (Figure 2).

FIGURE 1:Hypodense edema in the white matter on the non-contrast axial brain tomography image (A). Hyperintense edema in the white matter of the brain on the axial T2-weighted inversion recovery scan (FLAIR) image (B).

FIGURE 2:The axial (A), coronal (B), and sagittal (C) images of contrast-enhanced T1-weighted magnetic resonance imaging showing the foci of abscesses (tuberculomas) with peripheral enhancement.

The patient was diagnosed with tuberculous meningitis and related intracranial tuberculoma. Quadruple anti-TB therapy was commenced in addition to the administration of dexamethasone and mannitol to control intracranial pressure. Fluid and electrolyte management was also commenced. The lesions exhibited no significant regression following 6 months of therapy. Surgery was performed, and pathological examination confirmed the presence of necrotizing granulomatous inflammation associated with tuberculosis.

Tuberculomas are granulomatous masses arising from the hematogenous spread of M. tuberculosis 1 . These are hallmark features of severe extrapulmonary tuberculosis, present in approximately 5% of all cases of tuberculosis2. Imaging plays a crucial role in the early detection and differentiation of tuberculomas from other intracranial pathologies, thereby facilitating timely intervention and preventing long-term complications3.