Infratentorial Tuberculoma Mimics Tumor in Immunocompetent Adults: An Analysis of 11 Patients

Abstract

Backgrounds: Tuberculoma is a granulomatous inflammatory process mimicking a neoplasm, both clinically and radiologically. Although those with an infratentorial origin are rare, this disease is still a diagnostic challenge using conventional workup. However, this disease should not be overlooked because it is essentially curable with proper diagnosis and therapy, usually, a Mycobacterium Tuberculosis (MTB) DNA test is performed. Methods: We retrospectively analyzed the clinical presentations, CSF results, and images of 11 MTB DNA positive and clinically cured cases of infratentorial tuberculoma. Results: Infratentorial tuberculoma usually deteriorated before antituberculosis treatment (ATT). Magnetic resonance imaging showed space-occupying lesions without specific features, 4 within the cerebellum and 7 within the brainstem. Evidence of systemic tuberculosis was found in only 1 case. Clinical manifestations included various combinations of focal signs and symptoms in the brain stem and cerebellum. Cerebrospinal fluid (CSF) findings were also nonspecific. The diagnoses of these cases were based on the positive tests of a nested polymerase chain reaction (N-PCR) assay. Trial therapy with antituberculous drugs resulted in clinical improvement, as documented by MRI in all patients. Conclusions: Infratentorial tuberculoma should be suspected in patients with infratentorial space-occupying lesions who live in geographic areas where tuberculosis is endemic.

Right Gaze Palsy and Hoarseness: A Rare Presentation of Mediastinal Tuberculosis with an Isolated Prepontine Cistern Tuberculoma

“…Diagnosis of CNS tuberculomas is based on clinical findings and brain imaging. Stereotactic brain biopsy with histopathological examination may be required in the face of diagnostic uncertainty [ 12 ]. Differentials are broad including neoplastic (both primary and metastatic), parasitic, and fungal lesions especially in immunocompromised individuals.…”

“…CSF studies are usually nonspecific in the absence of concomitant meningitis. Elevated CSF protein is the most consistent finding, while CSF AFB stains and cultures are usually negative [ 11 , 12 ]. PCR for MTB DNA was positive in one case series [ 12 ].…”

“…Elevated CSF protein is the most consistent finding, while CSF AFB stains and cultures are usually negative [ 11 , 12 ]. PCR for MTB DNA was positive in one case series [ 12 ]. In the absence of stereotactic brain biopsy, response to empirical anti-TB therapy makes the diagnosis almost certain [ 11 ].…”

“…Continuing treatment would be prudent in this situation [ 14 , 15 ]. Systemic corticosteroids as adjuvant therapy are indicated when there is perilesional edema, elevated intracranial pressure, or paradoxical worsening due to enlargement of lesions during treatment [ 12 , 14 ]. Total resolution of the tuberculoma is observed when MRI images demonstrate no enhancing lesions or only an area of calcification [ 14 , 15 ].…”

Concurrent occurrence of both intracranial and intramedullary tuberculomas

“…[2] Infratentorial tuberculomas are more frequent in children, whereas lesions are mostly supratentorial in adults. [3] Intramedullary tuberculoma of the spine is a rare manifestation of disseminated tuberculosis, usually in young people and most commonly involve the thoracic spinal cord. [4] Its incidence is only 2 out of 100,000 cases of all tuberculosis.…”