Intramedullary Conus Medullaris Tuberculoma: A Case Report and Review of the Literature

Abstract

Intramedullary tuberculoma (IMT) of the conus medullaris is extremely rare. We present a case of intramedullary conus medullaris tuberculoma in which the diagnosis was based on there being very high levels of adenosine deaminase (ADA) in the patient’s cerebrospinal fluid (CSF) and improvement with antituberculous therapy. A 78-year-old man presented after having had a dull ache in both thighs and progressive paraparesis. The patient’s medical history included diffuse large B-cell lymphoma, which had undergone remission due to chemotherapy two years earlier, and long-term, well-controlled diabetes. A chest X-ray showed no evidence of tuberculosis. The results of CSF analysis were compatible with Froin’s syndrome. An initial diagnosis was made of an intramedullary tumor of the conus medullaris, based on magnetic resonance imaging (MRI). A myelotomy and multiple punch out biopsy were performed, and histopathology of the tissues revealed mild reactive gliosis. Due to the patient having high levels of CSF-ADA, IMT of the conus medullaris was suspected. The patient was treated with an 18-month course of antituberculous therapy. The dull ache gradually disappeared, and motor power improved slightly. A follow-up MRI of the lumbosacral (LS) spine revealed that the lesion had completely disappeared. Intramedullary tuberculoma of the conus medullaris should be considered in patients with underlying malignancy and no symptoms of systemic tuberculosis. CSF adenosine deaminase levels can be helpful in determining the presence of central nervous system tuberculosis when other systemic signs of disease are lacking.

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

“…Cranial tuberculous meningitis, intracranial tuberculomas, and Pott’s disease are the most frequent forms of CNS TB, with tuberculous spondylitis and arachnoiditis being the most common forms seen in the spine. [ 1 2 7 ] The brain, to spinal cord involvement ratio is approximately 42.3:1, and correlates very well to brain and spinal cord weight ratio, and their blood supplementation ratio as well. [ 4 12 13 14 ] The presence of isolated spinal intramedullary tuberculomas (IMT), without corresponding bony and meningeal involvement is very rare, right from when it was first reported by Abercrombie in 1828, there are only about 171 cases in the literature to date and mostly involves the thoracic spinal cord.…”

“…Tuberculous disease of the central nervous system (CNS) commonly presents as tuberculous meningitis, which is also the most common form of spinal intradural tuberculosis. [ 1 2 3 4 5 ] The occurrence of spinal intramedullary tuberculoma (IMT) is an uncommon disease, with roughly 171 cases having been reported to date, and the most favoured site of IMT is the thoracic spine. [ 2 5 6 7 8 ] The condition occurs in relatively young patients and is often associated with extra-spinal tuberculous disease or in immunosuppressed disease state.…”

“…[ 1 2 3 4 5 ] The occurrence of spinal intramedullary tuberculoma (IMT) is an uncommon disease, with roughly 171 cases having been reported to date, and the most favoured site of IMT is the thoracic spine. [ 2 5 6 7 8 ] The condition occurs in relatively young patients and is often associated with extra-spinal tuberculous disease or in immunosuppressed disease state. [ 2 5 6 7 ] Intramedullary location of conus medullaris tuberculoma is extremely rare, and in immunocompetent patients with no clinical features or history of tuberculosis, such diagnosis could be difficult, more also that Magnetic resonance imaging (MRI) features of the lesion vary considerably depending on the stage of disease.…”

“…[ 2 5 6 7 8 ] The condition occurs in relatively young patients and is often associated with extra-spinal tuberculous disease or in immunosuppressed disease state. [ 2 5 6 7 ] Intramedullary location of conus medullaris tuberculoma is extremely rare, and in immunocompetent patients with no clinical features or history of tuberculosis, such diagnosis could be difficult, more also that Magnetic resonance imaging (MRI) features of the lesion vary considerably depending on the stage of disease. [ 5 9 ] The rare nature of this disease in the conus medullaris and the lack of specific clinical and imaging features make the pre-operative diagnosis of this benign disease a daunting task, despite its potential for excellent recovery with adequate treatment.…”

Intramedullary Spinal Tuberculoma: An Uncommon Presentation of a Common Disorder

“…Intramedullary tuberculomas constitute about 0.2% to 0.5% of all central nervous system (CNS) tuberculomas [ 3 ]. About 170 cases of isolated IMT have been reported to date with the thoracic spinal cord being the most common site of involvement ­­­[ 4 ]. Intramedullary involvement by TB usually presents as transverse myelitis, radiculomyelitis, intraspinal granulomas, or thrombosis of the anterior spinal artery.…”