Intracranial tuberculomas accompanied by a singular intramedullary tuberculoma

A 62-year-old male, born in São Tomé, former ship kitchen assistant and without relevant medical history, was brought to the Emergency Department due to encephalopathy, cough, and thoracic pain that had been developing for two weeks. On examination, there were no signs of meningeal involvement or focal neurological deficits.

Brain MRI revealed multiple small lesions, measuring up to 1 cm in diameter, primarily involving both cerebral hemispheres, in particular at the junction of the grey and white matter.

These lesions were iso-hypointense on T1 with variable signal intensity on T2/FLAIR (mostly iso-hypointense). The majority displayed ring-like post-gadolinium enhancement and central diffusion restriction on diffusion-weighted imaging; the remaining lesions were smaller and presented solid enhancement after gadolinium. Associated perilesional oedema was also present.

Following the brain MRI, and due to progressive paraparesis, a spinal MRI was conducted one month later which revealed a single intramedullary lesion at D11 level with similar imaging features to the intracranial lesions previously described (hyperintense core and a hypointense rim on T2- weighted images, ring-like enhancement and perilesional oedema.

Background

Of all tuberculosis cases, 15% are related to extra-pulmonary tuberculosis, with approximately 10% of those cases located in the central nervous system (CNS) [1]. CNS involvement is often due to hematogenous spread from the lung [1].

Tuberculous meningitis is the most frequent manifestation of CNS involvement, while tuberculoma is a less prevalent presentation [2]. The occurrence of a tuberculoma in the spine is extremely rare and constitutes only 0.2–5% of all CNS tuberculomas [2].

Clinical Perspective

Intracranial tuberculomas can occur at any age, but usually, young adults are most affected [3]. The clinical presentation is variable and depends on the location, size, and number of lesions [3].

Intramedullary tuberculomas usually present with progressive subacute spinal cord compression with weakness in the lower limbs, which may cause flaccid or spastic paraplegia, paresthesias, urinary and faecal incontinence, and sensory level [4].

Diagnosing CNS tuberculomas can be challenging, but the presence of associated pulmonary involvement can aid in the diagnosis [5]. Cerebrospinal fluid (CSF) analysis might be normal when tuberculomas are the only CNS manifestation [6].

As the diagnosis of CNS tuberculomas can be challenging, the use of MRI is crucial for the diagnosis and evaluation of other manifestations of tuberculosis, such as meningitis and abscesses, and their complications [7].

Imaging Perspective

Tuberculomas are typically characterized as small lesions, with a diameter of less than 2.5 cm and three types of tuberculomas have been described: noncaseating, caseating with solid centre, and caseating with necrotic centre, according to MRI findings [7]. Noncaseating granulomas are usually hypointense on T1, T2, and T2 FLAIR, and exhibit homogeneous nodular enhancement. Caseating granulomas appear relatively hypo-isointense on T1, iso-hypointense on T2 and exhibit ring-like enhancement. Liquefied areas may be T2 hyperintense with a hypointense rim [7].

Outcome

The primary treatment approach for patients with CNS tuberculomas, including intra-medullary tuberculoma, involves anti-tuberculosis therapy and anti-edema measures. Typically, conservative treatment yields positive results, resulting in complete clinical neurological recovery within a year, along with the resolution of tuberculomas. Surgery is only considered for patients with significant compression caused by large lesions, or for patients who do not respond to or deteriorate during conservative treatment [2].

Written informed patient consent for publication has been obtained.