Intramedullary Tuberculoma of the Conus Medularis in an Immunocompetent Young Adult with no Pulmonary Tuberculosis, the Challenges of Diagnosis and Management: A Case Report and Review of Literature

Abstract

Background and objective: Intramedullary tuberculoma (IMT) of the conus medullaris is an extremely rare tumour that constitutes a diagnostic and management challenge in a resource-limited setting. We report a case of conus medullaris, IMT in a young immunocompetent, patient with no prior clinical features of pulmonary or extra-pulmonary tuberculosis.

Case summary: The patient presented with six months history of progressive and persistent mid back pain and slight weakness of both lower limbs of 3 months duration. Physical examination revealed a well-nourished man with power of 3/5 and hyperreflexia on both lower limbs. Chest radiograph and other investigations for tuberculosis were negative. Magnetic resonance imaging (MRI) of the lumbosacral spine showed fusiform expansion of the conus medullaris, with a well circumscribed, ring enhancing, intramedullary mass straddle between T12 and L1. Patient had gross total resection with no intraoperative monitoring assistance and no post-operative worsening of neurological function. Histology showed granulomatous lesion with central caseation in keeping with a tuberculoma. Patient was commenced on post-operative anti-tuberculous therapy with physiotherapy, with full motor recovery at six months post-surgical intervention and anti-tuberculous therapy.

Conclusion: Intramedullary tuberculoma can be considered as one of the differential diagnoses of intradural, intramedullary tumour of the conus, even in immunocompetent individual with no clinical features of tuberculosis.

Keywords: Conus medullaris; We present a patient with intramedullary tuberculoma of the conus medullaris in an immunocompetent young patient with no clinical features of pulmonary or extrapulmonary tuberculosis, who had Gross Total Resection with preserved neurological function.; intra-medullary; intra-operative monitoring; tuberculoma.

Figure 1

Non contrast, T2 and T1 magnetic resonance imaging of the thoracolumbar spine; showing a hypo-intense lesion straddle between T12 and L1, with surrounding oedema on a mid-sagittal TW2 magnetic resonance imaging, while iso-intense fusiform dilatation of the conus is seen on TW1 magnetic resonance imaging (green arrows)

Figure 2

T1 gadolinium-enhanced magnetic resonance imaging of the thoracolumbar spine, showing a well define, ring enhancing, intramedullary mass straddle between T12 and L1 (green arrows)

Figure 3

(a) The green arrows above showing tumour and the arrow below showing dura edge on the left. (b) Showing completely excised tumour. (c) Green arrow central area of caseation. (d) Histology showing granulomatous lesion