Intracerebral tuberculomas: A rare cause of seizure in an immunocompetent young male

Abstract

Central nervous system (CNS) involvement occurs in about 1% of all tuberculosis (TB) cases, classically presenting as a meningitis. Intracerebral tuberculomas are a much rarer manifestation. We describe the case of a young black male who presented with new-onset seizure. Cerebral computerized tomography from an outside hospital reportedly showed findings concerning for septic emboli. Brain magnetic resonance imaging at our institution confirmed the presence of multiple, peripherally enhancing lesions in the right frontal and temporal lobes, cerebellum, and pons. Thoracentesis was performed for a concomitant pleural effusion, which contained elevated levels of adenosine deaminase and ultimately grew Mycobacterium tuberculosis . After ruling out other causes, we reached a diagnosis of CNS TB manifesting as cerebral tuberculomas. The patient was initiated on a course of rifampin, isoniazid, pyrazinamide, and ethambutol for two months, followed by rifampin and isoniazid to complete at least twelve months of antimicrobial therapy. We present this case to highlight this unusual manifestation of CNS TB and review the challenges in diagnosis.

Analysis of Tuberculosis Meningitis Pathogenesis, Diagnosis, and Treatment

“…Extrapulmonary TB begins when the bacteria disseminate from the lungs to the lymph nodes, and during this time, there is bacteremia which seed M. tuberculosis to other organs in the body for TB, specifically the meninges and the brain parenchyma [ 17 , 18 ]. During hematogenous dissemination, mycobacteria may be deposited adjacent to the ventricles or subarachnoid space, leading to granuloma formation at those sites of deposition [ 19 , 20 ]. M. tuberculosis can breach the blood brain barrier (BBB) extracellularly or intracellularly via dendritic cells or macrophages [ 17 , 21 ].…”

“…The traditional treatment for pulmonary TB has been standardized to the RIPE [rifampin (RIF), isoniazid (INH), pyrazinamide, ethambutol) therapy for 2 months followed by RI (rifampin, isoniazid) for 10 months [ 20 , 23 , 37 , 38 , 39 ]. The empirical treatment for TBM remains the same as the treatment for pulmonary TB; the empirical treatment is warranted when clinical features and CSF findings are suggestive of TBM, even before microbiologic confirmation, since timely treatment dramatically improves the outcome of TBM [ 20 , 23 ].…”

“…It is worth mentioning that patients who present with TB with past medical history conditions are not treated similarly. For example, HIV patients are given the standard regimen of 2 months RIPE followed by 10 months of RI, but also given an ART therapy after [ 20 , 23 , 37 , 38 , 39 ]. Patients who develop syndrome of inappropriate antidiuretic hormone (SIADH) from M. tuberculosis infection should engage in fluid restriction and take medications such as furosemide and demeclocycline.…”

Central nervous system and spinal cord tuberculosis: Revisiting an important disease

“…TB-IRIS is one of the most important complications related to patients with HIV infection who started antiretroviral treatment. Neurological manifestations occur in almost 10% of cases [46].…”

Aggressive intracerebral tuberculoma in a 1-year-old child: A case report with literature review

“…The prevalence of Central nervous system tuberculoma is a rare entity that accounts about 1% of all tuberculosis (TB) and remains a serious global public health problem in world especially in the developing countries. It is a severe form of Intracranial granulomatous caused by the hematogenous spread of Mycobacterium tuberculosis infection from the primary site to the brain parenchyma, ventricle, and meninges [1 , 2] , and carries significant mortality and morbidity [3] . Cerebral TB can arise anywhere in the brain, but usually areas with abundant blood supply.…”