Tuberculosis of the cavum revealed by acute facial pain

Abstract

An 85-year-old woman presented for assessment of recurring episodes of intense hemifacial pain, mimicking trigeminal neuralgia, associated with tinnitus. A necrotic tumour of the cavum with compression of the left Eustachian tube and skull-base invasion was discovered on brain MRI. Although the tumour was initially thought to be malignant, the histopathological findings on the biopsy were compatible with tuberculosis, later confirmed by the cultures. F-18-fluorodeoxyglucose positron emission tomography (PET)/CT showed an intense signal of the cavum, cervical and mediastinal lymph nodes, and also of two small nodules of the apex of each lung. Currently, after 9 months of combined antituberculosis antibiotics, the initial lesion has almost disappeared from both PET scan and MRI. This case highlights the importance of systematically screening for tuberculosis in the assessment of nasopharyngeal tumours.

Figure 1

Coronal (A) and sagittal (B) T1-weighted MRI showing a necrotic tumour in the cavum, with peripheral gadolinium enhancement (arrows), compression of the left Eustachian tube and skull-base invasion.

Figure 2

F-18-fluorodeoxyglucose positron emission tomography/CT performed before (A), 2 months after (B), and at the end of antituberculosis therapy (C), showing a high level of F-18 uptake by the tumour, which progressively decreased and disappeared with the antituberculosis therapy (the level of F-18 uptake was determined by the SUV_max, as indicated).

Figure 3

(A) Chest X-ray showing only mild perihilar congestion. (B) Axial chest CT scan showing two small nodules in the apex of each lung and (C) F-18-fluorodeoxyglucose positron emission tomography/CT revealing a hyperintense signal of two pulmonary nodules and mediastinal lymph nodes.