Concurrent Multilevel Spinal Intra-medullary with Extensive Intracranial Tuberculomas: A Rare Case Report

Abstract

Disseminated tuberculomas in the brain and spinal cord are rare. To the best of our knowledge, only nine cases of spinal intra-medullary tuberculomas with cranial involvement have been reported till date. However, involvement of all levels in the spinal cord, brain stem with pan lobar involvement of the cerebrum and cerebellum has not been reported so far. We present such a case of a 12-year-old boy with history of pulmonary tuberculosis, who presented with gradual onset of quadriparesis and generalized seizures. We have discussed the unusual clinical presentation and the temporal changes in magnetic resonance imaging features along with clinical response to treatment. In cases reported so far, the plan of surgical versus medical management has been opted for variably, in cases of spinal intra-medullary involvement with acute neurological deficit. The decision is even more difficult in multilevel spinal intra-medullary tuberculomas. Our patient showed good clinico-radiological improvement with medical management.

Keywords: Central nervous system infection; concomitant cranio-spinal tuberculoma; intracranial tuberculoma; spinal tuberculoma; tuberculoma.

Figure 1

Magnetic resonance imaging brain T₁-contrast imaging showing multi-lobar tuberculomas diffusely enhancing with contrast. Sagittal, coronal, and axial contrast images revealing homogenous enhancing lesions (a-c respectively)

Figure 2

Magnetic resonance imaging spine T₁-contrast and Craniovertebral junction contrast imaging showing multilevel spinal involvement of tuberculomas—cervicomedullary, cervical lesions (a), cervical and dorsal spinal lesions (b), conus lesions (c)

Figure 3

Sagittal, coronal, and axial magnetic resonance imaging T₁-contrast images showed evolution to a ring enhancing lesion with reduction in enhancement after 3 months of treatment (a-c respectively) which showed complete resolution after treatment (d-f). Similar resolution also noted in cervical and dorsal spine (g,h)