Presentation, diagnosis, and treatment of a cerebellar tuberculoma: illustrative case

Abstract

Background: Central nervous system (CNS) tuberculomas are a feared complication of tuberculosis (TB) infection. These lesions can present in varying manners and are associated with significant morbidity and mortality. Prompt diagnosis and treatment of the lesion and the underlying infection are critical in the care of these patients. The authors presented a case of a 45-year-old Yemeni immigrant presenting with a 3-month history of severe right temporo-occipital headaches with photophobia and night sweats. Imaging showed a rim-enhancing lesion in the right cerebellar hemisphere.

Observations: Laboratory tests were unremarkable and within normal limits. QuantiFERON testing was negative, ruling out latent TB infection. The patient received a suboccipital craniotomy, and resection of the cerebellar lesion showed caseating granuloma formation, which was positive for acid-fast bacilli and Fite stain.

Lessons: CNS tuberculomas are an important differential to consider in patients with a history of primary TB, regardless of active disease or immunocompetent status. Resection of these lesions remains a viable treatment option that is safe and effective.

Keywords: AFB = acid-fast bacilli; CNS = central nervous system; CSF = cerebrospinal fluid; CT = computed tomography; MRI = magnetic resonance imaging; NAAT = nucleic acid-based amplification technique; RIPE = isoniazid, rifampin, ethambutol, and pyrazinamide; TB = tuberculosis; cerebellar; granuloma; infection; tuberculoma; tuberculosis.

FIG. 1.

Noncontrast head CT of the patient showing the brain (left) and bone (right) windows demonstrates a solitary calcified mass in the right cerebellar hemisphere with surrounding vasogenic edema.

FIG. 2.

Brain MRI performed preoperatively. T1 postcontrast imaging (left) demonstrates a heterogenous peripherally enhancing lesion in the posterior right cerebellar hemisphere with irregular margins and surrounding presumed vasogenic edema. T2 imaging (right) shows an isointense to mildly hyperintense signal with avid irregular enhancement. These findings are consistent with the posterior fossa calcified mass demonstrated on CT.

FIG. 3.

A: Microscopically, hematoxylin and eosin stain of the lesion revealed areas of central necrosis surrounded by epithelioid cells and inflammatory cells (magnification ×100). B: Other areas show multinucleated giant cells, epithelioid cells, and inflammatory cells consistent with necrotizing granuloma (magnification ×200). Staining for AFB (C, magnification ×1,000) and FITE (D, magnification ×1,000) are positive for acid-fast mycobacteria (black circles).