Indian J Pediatr DOI 10.1007/s12098-015-1820-5
SCIENTIFIC LETTER
Concurrent Intramedullary and Intracerebral Tuberculoma Ankita Goel 1 & Suvasini Sharma 2 & Puneet Jain 3 & Atin Kumar 4 & Satinder Aneja 2
Received: 24 March 2015 / Accepted: 9 June 2015 # Dr. K C Chaudhuri Foundation 2015
To the Editor : CNS-tuberculosis affects around 0.5–2 % of patients with systemic-tuberculosis [1]. Intramedullarytuberculoma is a very rare-form of CNS-tuberculosis with the reported incidence being 2 per 100,000 cases of tuberculosis and 2 per 1000 cases of CNS-tuberculosis [2]. A pre-morbidly normal, appropriately immunized, 18-moold girl presented with gradual loss of ambulation with urinary frequency and dribbling for the past 1 mo. There was no history of fever, cough, weight loss, seizures, altered sensorium, cranial nerve or upper limb involvement. There was no history of contact. On examination, the child was malnourished with symmetrical flaccid paraparesis of lower limbs (grade 3/5), exaggerated muscle stretch reflexes, absent abdominal reflex, preserved anal reflex, upgoing plantar response and no sensory
* Suvasini Sharma [email protected] 1
Department of Pediatrics, Lady Harding Medical College and Associated Kalawati Saran Children Hospital, New Delhi, India
2
Division of Pediatric Neurology, Department of Pediatrics, Lady Harding Medical College and Associated Kalawati Saran Children Hospital, New Delhi 110001, India
3
Division of Pediatric Neurology, Department of Neonatal, Pediatric and Adolescent Medicine, BL Kapur (BLK) Super Speciality Hospital, Pusa Road, New Delhi, India
4
Department of Radio-Diagnosis, All India Institute of Medical Sciences (AIIMS), New Delhi, India
loss. Spine and rest of the systemic examination was unremarkable. MRI spine (Fig. 1a and b) and CT head (Fig. 2) are shown. Lumbar puncture revealed neutrophilia, elevated-protein and hypoglycorrhacia. Tuberculin-test (2-TU) was positive (18 mm) with normal chest radiograph and negative HIV serology. CECT chest showed multiple conglomerate necrotic peripherally enhancing mediastinal lymph nodes with no parenchymal lesion. Child was started on steroids and antitubercular treatment: HRZE for 2 mo followed by HR for 16 mo. There was an improvement in power to grade 4/5 with some residual spasticity. Repeat neuroimaging done 6 mo afterwards showed marked decrease in the size of cord lesion (Fig. 3). Spinal intramedullary tuberculomas usually presents between 18 and 45 y of age, involve thoracic cord and are often associated with tuberculous foci elsewhere. They have been described in both immunocompromised and immunocompetent patients and present with subacute cord compression with or without sphincter dysfunction. Co-occurrence of intracerebral and intramedullary tuberculomas is exceedingly rare with only few pediatric case reports [3, 4]. The cerebral lesion in most-cases is clinically silent and an asymptomatic pulmonary focus can usually be picked up. Magnetic-resonance-imaging has enabled accurate diagnosis of the intramedullary tuberculoma lesions obviating the need for any biopsy [5]. The lesion appears hypointense to isointense on T1-weighted images, hypointense with or without central hyperintensity on T2-weighted images and usually shows peripheral enhancement. Other differential diagnoses such as
Indian J Pediatr
Fig. 1 MRI spine of the patient. T2W (a) and post contrast T1W (b) sagittal MR images of the cervicodorsal spine shows a large ring lesion in the cord opposite D1 to D3 vertebral level showing thick walls and peripheral enhancement suggestive of intramedullary tuberculoma. There was also enlargement of spinal cord, with long segment fluid filled widened central canal involving cord from C1/2 to D12/L1 vertebral levels (not shown)
neurocysticercosis, lymphoma, or metastasis also need to be considered. Most patients have good functional recovery with antituberculous treatment with neurological sequalae in others.
Fig. 3 Follow up MRI spine of the patient. Follow up contrast enhanced T1W Sagittal MR image of the spine done after 6 mo of ATT shows marked decrease in the size of the cord lesion
Surgica excision is required in cases with severe cord compression and clinical deterioration despite adequate medical therapy. Thus, spinal intramedullary tuberculoma is a rare differential diagnosis of spinal space occupying lesion causing paraparesis and should be promptly diagnosed and evaluated as it is amenable to cure by medical or surgical management. Conflict of Interest None. Source of Funding None.
References 1.
Fig. 2 CECT brain of the patient. Axial contrast enhanced CT of the brain of same time also showed a tuberculoma in the right frontal lobe with perilesional edema. There was similar lesion in left cerebellar hemisphere (not shown)
Naim-Ur-Rehman. Intracranial tuberculomas diagnosis and management. Acta Neurochir. 1987;88:109–15. 2. Mac Donnell AH, Baird RW, Bronze MS. Intramedullary tuberculomas of the spinal cord: case report and review. Rev Infect Dis. 1990;12:432–9. 3. Chitre PS, Tullu MS, Sawant HV, et al. Co-occurrence of intracerebral tuberculoma with lumbar intramedullary tuberculoma. J Child Neurol. 2009;24:606–9. 4. Kulkarni K, Kaur S, Gupta V, Rastogi H. Concurrent intramedullary and intracranial tuberculomas in a child with tubercular meningitis. BMJ Case Rep. 2010;2010. doi:10.1136/bcr.12.2009.2569. 5. Lu M. Imaging diagnosis of spinal intramedullary tuberculoma: case reports and literature review. J Spinal Cord Med. 2010;33:159–62.
SCIENTIFIC LETTER
Concurrent Intramedullary and Intracerebral Tuberculoma Ankita Goel 1 & Suvasini Sharma 2 & Puneet Jain 3 & Atin Kumar 4 & Satinder Aneja 2
Received: 24 March 2015 / Accepted: 9 June 2015 # Dr. K C Chaudhuri Foundation 2015
To the Editor : CNS-tuberculosis affects around 0.5–2 % of patients with systemic-tuberculosis [1]. Intramedullarytuberculoma is a very rare-form of CNS-tuberculosis with the reported incidence being 2 per 100,000 cases of tuberculosis and 2 per 1000 cases of CNS-tuberculosis [2]. A pre-morbidly normal, appropriately immunized, 18-moold girl presented with gradual loss of ambulation with urinary frequency and dribbling for the past 1 mo. There was no history of fever, cough, weight loss, seizures, altered sensorium, cranial nerve or upper limb involvement. There was no history of contact. On examination, the child was malnourished with symmetrical flaccid paraparesis of lower limbs (grade 3/5), exaggerated muscle stretch reflexes, absent abdominal reflex, preserved anal reflex, upgoing plantar response and no sensory
* Suvasini Sharma [email protected] 1
Department of Pediatrics, Lady Harding Medical College and Associated Kalawati Saran Children Hospital, New Delhi, India
2
Division of Pediatric Neurology, Department of Pediatrics, Lady Harding Medical College and Associated Kalawati Saran Children Hospital, New Delhi 110001, India
3
Division of Pediatric Neurology, Department of Neonatal, Pediatric and Adolescent Medicine, BL Kapur (BLK) Super Speciality Hospital, Pusa Road, New Delhi, India
4
Department of Radio-Diagnosis, All India Institute of Medical Sciences (AIIMS), New Delhi, India
loss. Spine and rest of the systemic examination was unremarkable. MRI spine (Fig. 1a and b) and CT head (Fig. 2) are shown. Lumbar puncture revealed neutrophilia, elevated-protein and hypoglycorrhacia. Tuberculin-test (2-TU) was positive (18 mm) with normal chest radiograph and negative HIV serology. CECT chest showed multiple conglomerate necrotic peripherally enhancing mediastinal lymph nodes with no parenchymal lesion. Child was started on steroids and antitubercular treatment: HRZE for 2 mo followed by HR for 16 mo. There was an improvement in power to grade 4/5 with some residual spasticity. Repeat neuroimaging done 6 mo afterwards showed marked decrease in the size of cord lesion (Fig. 3). Spinal intramedullary tuberculomas usually presents between 18 and 45 y of age, involve thoracic cord and are often associated with tuberculous foci elsewhere. They have been described in both immunocompromised and immunocompetent patients and present with subacute cord compression with or without sphincter dysfunction. Co-occurrence of intracerebral and intramedullary tuberculomas is exceedingly rare with only few pediatric case reports [3, 4]. The cerebral lesion in most-cases is clinically silent and an asymptomatic pulmonary focus can usually be picked up. Magnetic-resonance-imaging has enabled accurate diagnosis of the intramedullary tuberculoma lesions obviating the need for any biopsy [5]. The lesion appears hypointense to isointense on T1-weighted images, hypointense with or without central hyperintensity on T2-weighted images and usually shows peripheral enhancement. Other differential diagnoses such as
Indian J Pediatr
Fig. 1 MRI spine of the patient. T2W (a) and post contrast T1W (b) sagittal MR images of the cervicodorsal spine shows a large ring lesion in the cord opposite D1 to D3 vertebral level showing thick walls and peripheral enhancement suggestive of intramedullary tuberculoma. There was also enlargement of spinal cord, with long segment fluid filled widened central canal involving cord from C1/2 to D12/L1 vertebral levels (not shown)
neurocysticercosis, lymphoma, or metastasis also need to be considered. Most patients have good functional recovery with antituberculous treatment with neurological sequalae in others.
Fig. 3 Follow up MRI spine of the patient. Follow up contrast enhanced T1W Sagittal MR image of the spine done after 6 mo of ATT shows marked decrease in the size of the cord lesion
Surgica excision is required in cases with severe cord compression and clinical deterioration despite adequate medical therapy. Thus, spinal intramedullary tuberculoma is a rare differential diagnosis of spinal space occupying lesion causing paraparesis and should be promptly diagnosed and evaluated as it is amenable to cure by medical or surgical management. Conflict of Interest None. Source of Funding None.
References 1.
Fig. 2 CECT brain of the patient. Axial contrast enhanced CT of the brain of same time also showed a tuberculoma in the right frontal lobe with perilesional edema. There was similar lesion in left cerebellar hemisphere (not shown)
Naim-Ur-Rehman. Intracranial tuberculomas diagnosis and management. Acta Neurochir. 1987;88:109–15. 2. Mac Donnell AH, Baird RW, Bronze MS. Intramedullary tuberculomas of the spinal cord: case report and review. Rev Infect Dis. 1990;12:432–9. 3. Chitre PS, Tullu MS, Sawant HV, et al. Co-occurrence of intracerebral tuberculoma with lumbar intramedullary tuberculoma. J Child Neurol. 2009;24:606–9. 4. Kulkarni K, Kaur S, Gupta V, Rastogi H. Concurrent intramedullary and intracranial tuberculomas in a child with tubercular meningitis. BMJ Case Rep. 2010;2010. doi:10.1136/bcr.12.2009.2569. 5. Lu M. Imaging diagnosis of spinal intramedullary tuberculoma: case reports and literature review. J Spinal Cord Med. 2010;33:159–62.
