Intracranial tuberculoma: a rare complication of extrapulmonary tuberculosis. Illustrative case

Abstract

Background: Intracranial tuberculomas are rare entities commonly seen only in low- to middle-income countries where tuberculosis remains endemic. Furthermore, following adequate treatment, the development of intracranial spread is uncommon in the absence of immunosuppression.

Observations: A 22-year-old man with no history of immunosuppression presented with new-onset seizures in the setting of miliary tuberculosis status post 9 months of antitubercular therapy. Following a 2-month period of remission, he presented with new-onset tonic-clonic seizures. Magnetic resonance imaging demonstrated interval development of a mass concerning for an intracranial tuberculoma. After resection, pathological analysis of the mass revealed caseating granulomas within the multinodular lesion, consistent with intracranial tuberculoma. The patient was discharged after the reinitiation of antitubercular medications along with a steroid taper.

Lessons: To the best of the authors' knowledge, this case represents the first instance of intracranial tuberculoma occurring after the initial resolution of a systemic tuberculosis infection. The importance of retaining a high level of suspicion when evaluating these patients for seizure etiology is crucial because symptoms are rapidly responsive to resection of intracranial tuberculoma masses. Furthermore, it is imperative for surgeons to recognize the isolation steps necessary when managing these patients within the operating theater and inpatient settings.

Keywords: CNS = central nervous system; CSF = cerebrospinal fluid; CT = computed tomography; DWI = diffusion-weighted imaging; MRI = magnetic resonance imaging; extrapulmonary tuberculosis; intracranial; tuberculoma.

FIG. 1.

A: Axial T2-weighted MRI sequence demonstrating a small, lobulated mass broadly abutting the dural margin along the right posterior superior temporal convexity without an enhancing dural tail (white arrow). B: Diffusion-weighted image demonstrating a small region of diffusion restriction centrally located within the lesion (white arrow). C: Axial postcontrast T1-weighted sequence demonstrating contrast enhancement of the lesion (white arrow). D: Coronal postcontrast T1-weighted sequence demonstrating contrast enhancement of the right posterior superior temporal convexity mass (white arrow).

FIG. 2.

Intraoperative image of the right posterior superior temporal convexity mass lesion demonstrating amenability to en bloc resection.

FIG. 3.

A and B: Gross pathological sections of the mass lesion showing “caseating” necrosis. C and D: Low-power microscopic views of the large confluent granulomas with central necrosis. E: Well-formed granulomas. F: Smear of necrotic granuloma material at the time of intraoperative consultation. C–F: Hematoxylin and eosin stain. Original magnification ×20 (C and E), original magnification ×10 (D), and original magnification ×40 (F).