Tuberculoma of spine mimicking intramedullary tumour: A case report

Abstract

Introduction: Spinal intramedullary tuberculoma (IMTB) is a rare disease that accounts for 1 to 2/100,000 patients with tuberculosis [1]. This case demonstrated that this patient had atypical presentations compared to common tuberculosis considering that IMTB cases are really rare.

Case presentation: A 19-year-old male presenting with back pain and weakness of both lower limbs, which started in the left lower limb and subsequently involved the right lower limb for three months. He had sensory impairment below T6 and hypoesthesia. He complained of urine hesitancy and a feeling of incomplete voiding of urine. He was on anti-tubercular treatment (ATT) for last two months. MRI exhibited hypointense portion on T1-weighted images. T2-weighted image also showed hypointensity at T6, which suggested for intramedullary mass. Excisional biopsy was suggestive for tuberculoma.

Discussion: In TB-endemic country like in Indonesia, tuberculoma should be considered as a differential diagnosis for intramedullary SOL irrespective of age or presence of extra-cranial focus of TB. MRI is the optimal tool for evaluating and diagnosing IMTB at an early stage and useful in follow-up. However, IMTB imaging characteristics may vary with immune response of individual or the stage of the tuberculoma formation [3]. The aim of early surgery is to decompress the spinal cord and achieve improvement in neurological function.

Conclusion: This case was reported to emphasize that early surgical decompression is required as a delay might cause damage to the spinal cord. This case also provides some evidences based data, thus contributing to the future research studies and clinical practice.

Keywords: Case report; Mimicking; Spinal cord tumour; Tuberculoma.

Fig. 1

Plain X-Ray. Left: Chest X-Ray AP view showed homogenous consolidation at the right upper lung. Middle: Thoracolumbal X-Ray AP view showed normal finding. Right: Thoracic X-Ray lateral view demonstrated no abnormalities.

Fig. 2

Resected specimen of intramedullary mass.

Fig. 3

MRI sagittal view. Left: T1-weighted image showed intramedullary hypointense mass within T6. Right: T2-weighted image demonstrated low signal intensity in T6 level.

Fig. 4

Histopathology. Top: This picture demonstrated granuloma with caseous necrosis. Histopathology revealed a granulomatous lesion with a central area of caseation in keeping with a tuberculoma (asterisk). Middle: Multiple giant cells and inflammatory cells at 10x magnification. Some histiocytes are forming multinucleated giant cells (arrow). Bottom: Epithelioid cells granuloma at 40x magnification. Edge of a necrotizing granuloma seen in a peripheral rim of epithelioid histiocytes (arrows) surrounding the central necrotic region (asterisk). External to the rim of histiocytes is an outer rim of lymphocytes and plasma cells.

Fig. 5

Axial T1-weighted MRI of T6 level, showing an intradural hypointense mass.