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Duvuru S, Sanker V, Naureen S, Prakash G, Sanjana R, Dave T. Non-osseous intradural tuberculoma of the thoracic spine with compressive myelopathy. Clin Case Rep 2023; 11:e8131. [PMID: 37927983 PMCID: PMC10622405 DOI: 10.1002/ccr3.8131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/14/2023] [Accepted: 10/16/2023] [Indexed: 11/07/2023] Open
Abstract
Key Clinical Message An uncommon form of CNS tuberculosis called non-osseous IDEM tuberculoma frequently results from paradoxical drug interactions. It should be considered one of the differentials when patients receiving ATT experience acute neurological impairment. Abstract Tuberculoma affecting the spinal cord is a rare condition in modern times. The occurrence of non-osseous intradural tuberculosis, specifically in the spine, is even more exceptional. In fact, it is uncommon to encounter an intradural extramedullary tuberculous granuloma that lacks radiological indications of vertebral involvement, especially within the thoracic region. We present a case of a patient with a neurological deficit caused by a non-osseous intradural tuberculoma in the thoracic region, without any associated bone involvement. The patient experienced a gradual deterioration of neurological function. An MRI of the thoracic spine revealed the presence of a tuberculoma located intradurally, extramedullary, and juxtamedullary of the T5 vertebra. The compression of the spinal cord resulted in paraparesis which was worsening to paraplegia. A D4-D6 laminectomy and microsurgical excision were performed under intraoperative neurophysiological monitoring (IONM), and the patient showed clinical recovery. Excellent clinical outcomes were achieved. However, it is crucial to consider the possibility of a non-osseous intradural tuberculoma as a rare condition when encountering a SOL, particularly in patients with a history of tuberculosis and spinal cord compression. In cases where a progressing neurological deficit is present, a combination of surgical intervention and anti-tuberculous treatment should be considered as the optimal approach.
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Affiliation(s)
- Shyam Duvuru
- Department of NeurosurgeryApollo Specialty HospitalsMaduraiTamil NaduIndia
| | - Vivek Sanker
- Team ErevnitesTrivandrumIndia
- Research Assistant, Department of NeurosurgeryTrivandrum Medical CollegeKeralaIndia
| | - Syed Naureen
- Team ErevnitesTrivandrumIndia
- UT MD Anderson Cancer CenterHoustonTexasUSA
| | - Gupta Prakash
- Team ErevnitesTrivandrumIndia
- Virgen Milagrosa University Foundation College of MedicineSan Carlos CityPhilippines
| | - Rajurkar Sanjana
- Team ErevnitesTrivandrumIndia
- Datta Meghe Institute of Higher Education and ResearchJNMCWardhaIndia
| | - Tirth Dave
- Team ErevnitesTrivandrumIndia
- Bukovinian State Medical UniversityChernivtsiUkraine
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Yunde A, Maki S, Furuya T, Ikeda JI, Ohtori S. A Case of Partial Resection of an Intradural Extramedullary Tuberculoma Resulting in Improvement of Lower Limb Paralysis. Cureus 2023; 15:e45017. [PMID: 37829976 PMCID: PMC10565713 DOI: 10.7759/cureus.45017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2023] [Indexed: 10/14/2023] Open
Abstract
Intradural extramedullary tuberculomas are a rare manifestation of tuberculosis that can lead to neurological deficits. We present a case of a 26-year-old male from Myanmar with lower limb weakness and gait disturbance, who was diagnosed with tuberculosis and found to have an intradural extramedullary lesion in the thoracic spine. Prompt surgical intervention was performed to address the lesion located at the T2-4 level. Although complete resection was hindered by strong adhesion, significant improvement in lower limb paralysis was achieved. The elasticity loss of the dura mater posed a challenge in suturing, necessitating duraplasty with a synthetic graft material. This case report emphasizes the potential significance of surgical intervention, including partial excision, in the management of intradural extramedullary tuberculomas. Surgical treatment can play a crucial role in improving neurological outcomes in patients with intradural extramedullary tuberculomas, even in challenging scenarios.
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Affiliation(s)
- Atsushi Yunde
- Department of Orthopaedic Surgery, Chiba University, Graduate School of Medicine, Chiba, JPN
| | - Satoshi Maki
- Department of Orthopaedic Surgery, Chiba University, Graduate School of Medicine, Chiba, JPN
| | - Takeo Furuya
- Department of Orthopaedic Surgery, Chiba University, Graduate School of Medicine, Chiba, JPN
| | - Jun-Ichiro Ikeda
- Department of Diagnostic Pathology, Chiba University, Graduate School of Medicine, Chiba, JPN
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Chiba University, Graduate School of Medicine, Chiba, JPN
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3
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Davis AG, Rohlwink UK, Proust A, Figaji AA, Wilkinson RJ. The pathogenesis of tuberculous meningitis. J Leukoc Biol 2019; 105:267-280. [PMID: 30645042 DOI: 10.1002/jlb.mr0318-102r] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/17/2018] [Accepted: 12/05/2018] [Indexed: 01/07/2023] Open
Abstract
Tuberculosis (TB) remains a leading cause of death globally. Dissemination of TB to the brain results in the most severe form of extrapulmonary TB, tuberculous meningitis (TBM), which represents a medical emergency associated with high rates of mortality and disability. Via various mechanisms the Mycobacterium tuberculosis (M.tb) bacillus disseminates from the primary site of infection and overcomes protective barriers to enter the CNS. There it induces an inflammatory response involving both the peripheral and resident immune cells, which initiates a cascade of pathologic mechanisms that may either contain the disease or result in significant brain injury. Here we review the steps from primary infection to cerebral disease, factors that contribute to the virulence of the organism and the vulnerability of the host and discuss the immune response and the clinical manifestations arising. Priorities for future research directions are suggested.
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Affiliation(s)
- Angharad Grace Davis
- The Francis Crick Institute, Midland Road, London, United Kingdom.,Faculty of Life Sciences, University College London, United Kingdom.,Department of Medicine, University of Cape Town, Republic of South Africa
| | - Ursula Karin Rohlwink
- Neuroscience Institute, Division of Neurosurgery, University of Cape Town, Republic of South Africa
| | - Alizé Proust
- The Francis Crick Institute, Midland Road, London, United Kingdom
| | - Anthony A Figaji
- Neuroscience Institute, Division of Neurosurgery, University of Cape Town, Republic of South Africa
| | - Robert J Wilkinson
- The Francis Crick Institute, Midland Road, London, United Kingdom.,Faculty of Life Sciences, University College London, United Kingdom.,Department of Medicine, University of Cape Town, Republic of South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Republic of South Africa.,Department of Medicine, Imperial College, London, United Kingdom
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4
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Kolakshyapati M, Takeda M, Mitsuhara T, Yamaguchi S, Abiko M, Matsuda S, Kurisu K. Isolated Tuberculoma Mimicking Foramen Magnum Meningioma in the Absence of Primary Tuberculosis: A Case Report. Neurospine 2018; 15:277-282. [PMID: 30145853 PMCID: PMC6226133 DOI: 10.14245/ns.1836034.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 05/14/2018] [Indexed: 12/02/2022] Open
Abstract
Central nervous system tuberculosis is a devastating complication of systemic tuberculosis. Intradural extramedullary (IDEM) tuberculoma at the foramen magnum is rare, and mimics en plaque meningioma. We report the case of a 53-year-old woman who presented with dysesthesia of the tongue and lower cranial nerve (CN) palsy, with onset 4 months prior to admission. The neurologic examination revealed left upper-limb weakness and hypoesthesia on the sole and dorsum of the left foot. Other physical examinations revealed no features of tubercular infection. Laboratory investigations likewise showed no signs of infection or inflammation. Magnetic resonance imaging of the brain showed an IDEM mass originating from the left intradural surface at the foramen magnum extending to the C2 segment and compressing the brainstem and upper cervical cord. The mass was isointense/hypointense on T1- and T2-weighted images and homogeneously-enhanced on postcontrast images. The lesion also exhibited the dural-tail sign and was preoperatively diagnosed as en plaque meningioma. The patient underwent surgery via the left transcondylar fossa approach with partial laminectomy of the atlas. Intraoperatively, the mass exhibited a dural origin and encased the vertebral artery and lower CNs, with strong adhesions. While the histopathological study of the mass was strongly suggestive of tuberculoma with multifocal granulomas, caseous necrosis, and Langerhans giant cells, extensive diagnostic studies failed to detect Mycobacterium tuberculosis itself. Although the patient had recurrence with multisystem involvement, she responded well to antitubercular treatment. IDEM tuberculoma of the foramen magnum may present as en plaque meningioma. Histopathology is required for a definitive diagnosis. Prompt surgical resection and decompression with adequate antitubercular treatment yield better neurological outcomes.
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Affiliation(s)
- Manish Kolakshyapati
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masaaki Takeda
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takafumi Mitsuhara
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Satoshi Yamaguchi
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masaru Abiko
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shingo Matsuda
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kaoru Kurisu
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Chen F, Chen L, Cao Y, Yi Y, Zhuang J, Le W, Xie W, Tu L, Li P, Fang Y, Li L, Kou Y, Fu K, He H, Ju H. Intracisternal tuberculoma: a refractory type of tuberculoma indicating surgical intervention. BMC Neurol 2018; 18:10. [PMID: 29347976 PMCID: PMC5772699 DOI: 10.1186/s12883-017-0996-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 11/29/2017] [Indexed: 11/16/2022] Open
Abstract
Background Central nervous system (CNS) tuberculoma is a rare disease with severe neurological deficits. This retrospective research is to review the data of patients diagnosed as CNS tuberculoma. Surgeries were performed in all patients. The clinical features especially the neurological image and the anatomical characters of the tuberculomas were concerned. Methods Totally 11 patients diagnosed as CNS tuberculoma were admitted in Guangzhou First People’s Hospital (7cases) and Changzheng Hospital (4 cases) during 2006–2015. The data including preoperative condition, neurological imaging, and surgical findings was collected and analyzed. Results The lesions of nine patients (9/11) were totally or subtotally excised and two (2/11) were partially excised. Neurological functions of all patients were improved after surgery without secondary infection. Lesions of nine (9/11) patients preoperatively progressed as a result of paradoxical reaction. Of the 9 patients demonstrated paradoxical progression, all lesions were partially or totally located at the cisterns or the subarachnoid space. Preoperative ATTs lasted 2 to 12 months and tuberculomas were not eliminated. The arachnoid was found thickened and tightly adhered to the lesions during surgeries. Of the 2 cases that paradoxical reaction were excluded, both patients (case 6, intramedullary tuberculoma; case 11, intradural extramedullary tuberculoma) were admitted at onset of the disease. ATTs were preoperatively given for 1 week as neurological deficits aggravated. The tuberculous lesions of CNS or other system showed no obvious change and paradoxical reaction could not be established in both cases. Conclusions Exudates of tuberculosis is usually accumulated in the cisterns and frequently results in the paradoxical formation of tuberculoma. Intracisternal tuberculoma is closely related to paradoxical reaction and refractory to anti-tuberculosis therapy. Micro-surgical excision is safe and effective. Early surgical intervention may be considered in the diagnosis of intracisternal tuberculoma especially when paradoxical reaction participates in the development of tuberculoma.
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Affiliation(s)
- Fanfan Chen
- Neurosurgery Department, Guangzhou First People's Hospital, Guangzhou Medical University, 1# Panfu Road, Guangzhou, Guangdong, 510180, China
| | - Lei Chen
- Neurosurgery Department, Shenzhen Second People's Hospital, Shenzhen University, 3002# Sungang Road, Shenzhen, 518037, China
| | - Yongfu Cao
- Neurosurgery Department, Guangzhou First People's Hospital, Guangzhou Medical University, 1# Panfu Road, Guangzhou, Guangdong, 510180, China
| | - Yongjun Yi
- Neurosurgery Department, Guangzhou First People's Hospital, Guangzhou Medical University, 1# Panfu Road, Guangzhou, Guangdong, 510180, China
| | - Jingwen Zhuang
- Neurosurgery Department, Guangzhou First People's Hospital, Guangzhou Medical University, 1# Panfu Road, Guangzhou, Guangdong, 510180, China
| | - Wuhua Le
- Neurosurgery Department, Guangzhou First People's Hospital, Guangzhou Medical University, 1# Panfu Road, Guangzhou, Guangdong, 510180, China
| | - Wei Xie
- Neurosurgery Department, Guangzhou First People's Hospital, Guangzhou Medical University, 1# Panfu Road, Guangzhou, Guangdong, 510180, China
| | - Lanbo Tu
- Neurosurgery Department, Guangzhou First People's Hospital, Guangzhou Medical University, 1# Panfu Road, Guangzhou, Guangdong, 510180, China
| | - Peng Li
- Neurosurgery Department, Guangzhou First People's Hospital, Guangzhou Medical University, 1# Panfu Road, Guangzhou, Guangdong, 510180, China
| | - Yimin Fang
- Tuberculosis Department, Guangzhou Chest Hospital, 62# Hengzhi Gang Road, Guangzhou, Guangdong, 510095, China
| | - Ling Li
- Record Department, Guangzhou First People's Hospital, Guangzhou Medical University, 1# Panfu Road, Guangzhou, Guangdong, 510180, China
| | - Yuqing Kou
- Department of Navy Medicine, The Second Military Medical University, 800# Xiangyin Road, Shanghai, 200433, China
| | - Kaikai Fu
- Department of Navy Medicine, The Second Military Medical University, 800# Xiangyin Road, Shanghai, 200433, China
| | - Hua He
- Neurosurgery Department, Changzheng Hospital, The Second Military Medical University;State key Laboratory of Drug Research, Shanghai Institute of Material Medical, Chinese Academy of Sciences, 415# Fengyang Road, Shanghai, 200003, China.
| | - Hongbin Ju
- Spinal Surgery Department, Guangzhou First People's Hospital, Guangzhou Medical University, 1# Panfu Road, Guangzhou, Guangdong, 510180, China.
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6
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Ghali MGZ, Srinivasan VM, Kim MJ, Malik A. Spinal Intramedullary Tuberculosis with Concurrent Supra- and Infratentorial Intracranial Disease in a 9-Month-Old Boy: Case Report and Comprehensive Review of the Literature. World Neurosurg 2017; 106:37-45. [PMID: 28532916 DOI: 10.1016/j.wneu.2017.05.069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/09/2017] [Accepted: 05/11/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Tuberculous involvement of the spinal cord parenchyma is an exceedingly rare clinical entity; even more so is concurrent intracranial tuberculosis (TB). Spinal intramedullary TB presents with a characteristic subacute myelopathy, with slowly progressive paraplegia, sensory deficits, and/or bowel and bladder dysfunction. Diagnosis is strongly suspected with a clinical history of known TB in conjunction with characteristic findings on magnetic resonance imaging. Management involves multiagent antitubercular chemotherapy without or with operative intervention. CASE DESCRIPTION We present a case of a 9-month-old boy with a retrospectively recognized history of pulmonary TB presenting with fever and back tenderness found to have lower-extremity hypertonia and clonus. Imaging revealed concurrent intracranial and spinal intramedullary tuberculomas. The patient was treated for hydrocephalus with external ventricular drainage followed by T8-T10 laminectomy, drainage of abscess, and duraplasty. Parietal lobe biopsies proved the tuberculous etiology of intracranial lesions. CONCLUSION Etiopathogenesis, diagnosis, and management considerations of spinal intramedullary tuberculosis are reviewed and discussed.
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Affiliation(s)
- Michael George Zaki Ghali
- Department of Neurobiology & Anatomy, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA; Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.
| | | | - Marc J Kim
- Department of Internal Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Archana Malik
- Department of Pediatric Radiology, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania, USA
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7
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Tuberculosis - 'The great masquerader' presenting as a dumb-bell-shaped intradural extramedullary tumor in a 20-year-old female. J Clin Orthop Trauma 2017; 8:168-170. [PMID: 28720995 PMCID: PMC5498742 DOI: 10.1016/j.jcot.2016.06.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 04/23/2016] [Accepted: 06/14/2016] [Indexed: 11/21/2022] Open
Abstract
Tuberculosis has been known as the great masquerader for its varied presentations. We present an extraordinary case of a 20-year-old female who presented with paraparesis of two months. MRI showed an intradural, extramedullary dumb-bell-shaped, spinal cord tumor. With a provisional clinicoradiological diagnosis of benign nerve sheath tumor (schwannoma/neurofibroma), laminectomy was done. But after durotomy, frank pus was drained from the site of lesion and the laboratory investigations of the tissue and pus obtained proved it to be tubercular. This is a rare case reported in the literature where tuberculosis is mimicking as a dumb-bell-shaped, spinal cord tumor.
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8
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Garg RK, Malhotra HS, Gupta R. Spinal cord involvement in tuberculous meningitis. Spinal Cord 2015; 53:649-57. [PMID: 25896347 DOI: 10.1038/sc.2015.58] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 02/24/2015] [Accepted: 03/04/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To summarize the incidence and spectrum of spinal cord-related complications in patients of tuberculous meningitis. SETTING Reports from multiple countries were included. METHODS An extensive review of the literature, published in English, was carried out using Scopus, PubMed and Google Scholar databases. RESULTS Tuberculous meningitis frequently affects the spinal cord and nerve roots. Initial evidence of spinal cord involvement came from post-mortem examination. Subsequent advancement in neuroimaging like conventional lumbar myelography, computed tomographic myelography and gadolinium-enhanced magnetic resonance-myelography have contributed immensely. Spinal involvement manifests in several forms, like tuberculous radiculomyelitis, spinal tuberculoma, myelitis, syringomyelia, vertebral tuberculosis and very rarely spinal tuberculous abscess. Frequently, tuberculous spinal arachnoiditis develops paradoxically. Infrequently, spinal cord involvement may even be asymptomatic. Spinal cord and spinal nerve involvement is demonstrated by diffuse enhancement of cord parenchyma, nerve roots and meninges on contrast-enhanced magnetic resonance imaging. High cerebrospinal fluid protein content is often a risk factor for arachnoiditis. The most important differential diagnosis of tuberculous arachnoiditis is meningeal carcinomatosis. Anti-tuberculosis therapy is the main stay of treatment for tuberculous meningitis. Higher doses of corticosteroids have been found effective. Surgery should be considered only when pathological confirmation is needed or there is significant spinal cord compression. The outcome in these patients has been unpredictable. Some reports observed excellent recovery and some reported unfavorable outcomes after surgical decompression and debridement. CONCLUSIONS Tuberculous meningitis is frequently associated with disabling spinal cord and radicular complications. Available treatment options are far from satisfactory.
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Affiliation(s)
- R K Garg
- Department of Neurology, King George Medical University, Uttar Pradesh, India
| | - H S Malhotra
- Department of Neurology, King George Medical University, Uttar Pradesh, India
| | - R Gupta
- Department of Neurology, King George Medical University, Uttar Pradesh, India
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9
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Garg RK, Malhotra HS, Kumar N. Paradoxical reaction in HIV negative tuberculous meningitis. J Neurol Sci 2014; 340:26-36. [PMID: 24680563 DOI: 10.1016/j.jns.2014.03.025] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 02/21/2014] [Accepted: 03/12/2014] [Indexed: 01/06/2023]
Abstract
This review focusses on paradoxical reactions occurring during the treatment of tuberculous meningitis (TBM) in human immunodeficiency virus-negative cases. A paradoxical reaction is defined as the worsening of a pre-existing lesion or the appearance of new lesion in a patient whose clinical symptoms initially improved with anti-tuberculosis treatment. A number of different paradoxical reactions have been reported in patients with TBM including expansion of existing cerebral tuberculomas, and appearance of new tuberculomas, hydrocephalus, and optochiasmatic and spinal arachnoiditis. While the exact mechanism of paradoxical reactions is uncertain, an exaggerated immune reaction against Mycobacterium tuberculosis-associated antigens is currently the most accepted theory for tuberculous paradoxical reaction. Corticosteroids are considered to have a beneficial effect in the management of paradoxical reactions. Immuno-modulatory drugs, including tumor necrosis factor-α antagonists, thalidomide and interferon-γ have been used in isolated cases with more severe forms of paradoxical reactions.
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Affiliation(s)
- Ravindra Kumar Garg
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India.
| | | | - Neeraj Kumar
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
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10
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Sahu R, Chaudhari TS, Junewar V, Shukla R. Spinal cord tuberculosis: a paradoxical response to antituberculous therapy. BMJ Case Rep 2014; 2014:bcr-2014-203639. [PMID: 24604804 DOI: 10.1136/bcr-2014-203639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ritesh Sahu
- Department of Neurology, King George's Medical University, Lucknow, Uttar Pradesh, India
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11
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Sharma B, Nagpal K, Handa R, Gupta P. Intradural extramedullary and intracranial tuberculomas with concurrent communicating syringomyelia. BMJ Case Rep 2014; 2014:bcr-2013-201368. [PMID: 24495974 DOI: 10.1136/bcr-2013-201368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Tuberculosis is the most common chronic central nervous system infection in developing countries like India. Non-osseous spinal cord involvement is a rare manifestation of tuberculosis. The use of MRI, as an imaging modality of choice, has revolutionised the imaging of tuberculomas with reasonable certainty and thereby avoiding unnecessary surgical intervention. We report an unusual presentation of intradural extramedullary and intracranial tuberculomas with communicating syringomyelia complicated with tubercular meningitis.
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Affiliation(s)
- Bhawna Sharma
- Department of Neurology, S.M.S Medical College, Jaipur, Rajasthan, India
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12
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Verma K, Crothers T, Neuman B, Vaccaro A, Heller J. Intradural Extramedullary Spinal Tuberculosis Diagnosed Eight Years After Treatment of the Primary Infection: A Case Report. JBJS Case Connect 2013; 3:e102. [PMID: 29252257 DOI: 10.2106/jbjs.cc.m.00080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Kushagra Verma
- Departments of Orthopaedic Surgery (K.V., A.V.) and Neurosurgery (J.H.), Thomas Jefferson University Hospital, 834 Chestnut Street #1432, Philadelphia, PA 19107.
| | - Tracey Crothers
- University of Southern California, 1200 North State Street, GNH 3900, Los Angeles, CA 90033
| | - Brian Neuman
- Washington University School of Medicine, Campus Box 8233, 660 South Euclid Avenue, Saint Louis, MO 63110
| | - Alexander Vaccaro
- Departments of Orthopaedic Surgery (K.V., A.V.) and Neurosurgery (J.H.), Thomas Jefferson University Hospital, 834 Chestnut Street #1432, Philadelphia, PA 19107.
| | - Joshua Heller
- Departments of Orthopaedic Surgery (K.V., A.V.) and Neurosurgery (J.H.), Thomas Jefferson University Hospital, 834 Chestnut Street #1432, Philadelphia, PA 19107.
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13
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Sandler AL, Thompson D, Goodrich JT, van Aalst J, Kolatch E, El Khashab M, Nejat F, Cornips E, Mohindra S, Gupta R, Yassari R, Daniels LB, Biswas A, Abbott R. Infections of the spinal subdural space in children: a series of 11 contemporary cases and review of all published reports. A multinational collaborative effort. Childs Nerv Syst 2013; 29:105-17. [PMID: 23053357 DOI: 10.1007/s00381-012-1916-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Accepted: 08/27/2012] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Positioned anatomically between the spinal epidural space and the intramedullary compartment, the spinal subdural space remains the least common area of localized infection in the central nervous system. Infectious processes of the subdural spinal space include subdural spinal empyema, subdural spinal abscess, infected spinal subdural cyst, and infectious spinal subdural cyst. To date, there has been no systematic review of these entities in children, with the cumulative knowledge of the pathophysiologic, microbiologic, and demographic characteristics of these infections relegated solely to few small series and case reports. METHODS A series of 11 recent cases culled from the collaboration of international authors are presented. In addition, an exhaustive MEDLINE search and manual review of the international literature was performed, identifying a total of 73 cases of spinal subdural infections in patients under the age of 21. Data of interest include the age, sex, signs, and symptoms at presentation, spinal location of infection, presence of spinal dysraphism, and other comorbidities, offending organism, treatment, outcome, and follow-up. RESULTS Patients ages ranged from 4 weeks to 20 years (mean, 6.5 years). Males outnumbered females by a ratio of 2:1. Over half (53 %) of spinal subdural infections in children were associated with spinal dysraphism or other congenital abnormalities of the spine. The commonest organism to infect the spinal subdural space in children is mycobacterium tuberculosis and the thoracic spinal region was most commonly infected. CONCLUSIONS The disease is usually treated surgically, although a more expectant approach consisting of antibiotics and observation has also been proposed.
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Affiliation(s)
- Adam L Sandler
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, 3316 Rochambeau Avenue, Bronx, NY 10467, USA.
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14
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Sohn S, Jin YJ, Kim KJ, Kim HJ. Long-term Sequela of Intradural Extramedullary Tuberculoma in the Thoracic Dorsal Spinal Cord: Case Report and Review of the Literature. KOREAN JOURNAL OF SPINE 2011; 8:295-9. [PMID: 26064149 PMCID: PMC4461743 DOI: 10.14245/kjs.2011.8.4.295] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Revised: 12/18/2011] [Accepted: 01/06/2012] [Indexed: 11/19/2022]
Abstract
A 45-year old man, who had tuberculosis five years ago presented with paresthesia, decreased proprioception, and gait disturbance in the lower extremity which were aggravated for a month. Magnetic resonance imaging revealed the T3-7 intradural extramedullary fibrotic mass with dark signal intensity on T2-weighted images. The yellowish material in the thick fibrous mass was confirmed as caseous necrosis. Two days after the operation, the symptoms improved. Although quite rare, intradural extramedullary tuberculoma should be considered as a chronic sequel of the previous medical history of pulmonary tuberculosis or tuberculous meningitis.
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Affiliation(s)
- Seil Sohn
- Department of Neurosurgery, Seoul National University College of Medicine, Bundang Hospital, Seongnam-si, Korea
| | - Yong Jun Jin
- Department of Neurosurgery, Seoul Paik Hospital, Inje University, Seoul, Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Bundang Hospital, Seongnam-si, Korea
| | - Hyun-Jib Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Bundang Hospital, Seongnam-si, Korea
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15
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Choi YS, Park KH, Choi DH. Co-occurrence of cervical and thoracic intradural extramedullary tuberculoma following tuberculosis meningitis. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.ejrex.2011.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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16
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17
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Shim DM, Oh SK, Kim TK, Chae SU. Intradural extramedullary tuberculoma mimicking en plaque meningioma. Clin Orthop Surg 2010; 2:260-3. [PMID: 21119945 PMCID: PMC2981785 DOI: 10.4055/cios.2010.2.4.260] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Accepted: 02/11/2010] [Indexed: 12/03/2022] Open
Abstract
A 24-year-old man with tuberculosis meningitis developed acute paraplegia and sensory disturbances 5 weeks after receiving conventional antituberculous therapy. Magnetic resonance imaging revealed an intradural extramedullary long segmental mass mimicking en plaque meningioma at the T2-T6 vertebrae levels. Prompt surgical decompression was performed. A histology examination of the mass revealed a tuberculoma. After surgery, the patient showed improved motor power and a normal bladder function. Intradural extramedullary tuberculoma of the spinal cord is rare complication of tuberculosis meningitis, which can occur as a response to conventional antituberculous therapy.
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Affiliation(s)
- Dae Moo Shim
- Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, Korea
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18
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Abstract
Nontumor lesions of the spinal cord and spine include developmental disorders, cystic tumor-like lesions, vascular disorders, infective diseases, demyelinating diseases, degenerative diseases, metabolic and toxic disorders, and spinal cord injury. In addition, diseases of the spine and extradural spaces secondarily cause spinal cord injury. Aside from tumors, these include developmental abnormalities, inflammatory diseases, nontumor space-occupying lesions, and tumor-like lesions such as lipomas, vascular malformations, and cysts. Awareness is required of hemostatic agents used during surgery and subsequently presenting as space-occupying lesions, which have to be differentiated from recurrent lesions. On the therapeutic front, stem cell transplantation into spinal cord for treatment of neurodegenerative disorders, spinal cord injury, and multiple sclerosis is a challenging prospect.
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Affiliation(s)
- Medha Tatke
- Department of Pathology, G.B. Pant Hospital, New Delhi, India.
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19
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Calaf F, Oleaga L, Sigritz N, Squarcia M, González S, Berenguer J. Magnetic resonance imaging findings of a case of an intradural-extramedullary tuberculoma of the spinal cord. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/j.ejrex.2008.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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20
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Muthukumar N, Sureshkumar V. Concurrent syringomyelia and intradural extramedullary tuberculoma as late complications of tuberculous meningitis. J Clin Neurosci 2008; 14:1225-30. [PMID: 18029276 DOI: 10.1016/j.jocn.2006.05.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2006] [Revised: 05/28/2006] [Accepted: 05/29/2006] [Indexed: 11/26/2022]
Abstract
Tuberculous meningitis (TBM) is a common presentation of extrapulmonary tuberculosis. TBM is associated with many complications. However, concurrent syringomyelia and intradural extramedullary tuberculoma occurring in a patient treated for TBM is rare. Only one such case has been reported earlier. A 27-year-old woman presented with paraparesis of 2 months duration. She had been treated for TBM 8 months earlier. She was found to have an extensive syringomyelia from C2 to the conus medullaris and an intradural extramedullary tuberculoma at the lower thoracic levels. At surgery, a thick, granulomatous lesion was found in the intradural extramedullary plane. Following excision of the granulomatous lesion, a syringostomy was done. The patient was treated with antituberculous drugs and steroids. Six months after treatment, there was no significant change in her neurological status. Concurrent syringomyelia and intradural extramedullary tuberculoma should be entertained in the differential diagnosis when a patient presents with myelopathy following TBM. The pathogenesis of syringomyelia in this condition is discussed.
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Affiliation(s)
- N Muthukumar
- Deparment of Neurosurgery, Madurai Medical College, Madurai, India.
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21
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Takahashi H, Ito S, Kojima S, Tanno T, Hattori T. Intradural extramedullary tuberculoma of the thoracic spine: paradoxical response to antituberculous therapy. Intern Med 2008; 47:797-8. [PMID: 18421202 DOI: 10.2169/internalmedicine.47.0839] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Intradural extramedullary tuberculoma of the spinal cord (IETSC) is a rare complication of tuberculosis, which can occur as a paradoxical response to antituberculous therapy. A 46-year-old woman with tuberculosis meningitis developed an acute sensory disturbance and paraplegia eight weeks after the antituberculous treatment was started. MRI revealed a cystic lesion at the Th 2 and 3 vertebrae levels, and continuous dural thickening. Laminectomy was performed; soft granulomas were unexpectedly observed inside the dura matter. After the operation, the patient experienced progressive improvement in motor strength. IETSC should be known as rare but possible complication of tuberculous meningitis.
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Affiliation(s)
- Hirokatsu Takahashi
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba.
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22
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Semlali S, Akjouj S, Chaouir S, Hanine A, Ben Ameur M. [Spinal subdural tuberculous abscess in a patient with tuberculous meningitis]. ACTA ACUST UNITED AC 2007; 88:280-1. [PMID: 17372557 DOI: 10.1016/s0221-0363(07)89816-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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23
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Harris B, Morris T. Central Nervous System Tuberculosis. J Nurse Pract 2007. [DOI: 10.1016/j.nurpra.2007.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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24
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Muthukumar N, Sureshkumar V, Ramesh VG. En plaque intradural extramedullary spinal tuberculoma and concurrent intracranial tuberculomas: paradoxical response to antituberculous therapy. Case report. J Neurosurg Spine 2007; 6:169-73. [PMID: 17330587 DOI: 10.3171/spi.2007.6.2.169] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spinal intradural extramedullary tuberculoma is a rare entity. Rarer still are extensive en plaque intradural extramedullary tuberculomas occurring concurrently with multiple intracranial tuberculomas as a paradoxical response to chemotherapy for tuberculosis (TB). The authors describe the case of a 21-year-old man who was treated for tuberculous meningitis. Three months after the episode of meningitis, while undergoing chemotherapy for TB, he developed features of thoracic myelopathy. Investigations revealed an extensive en plaque intradural extramedullary lesion spanning seven segments in the lower thoracic spine. Magnetic resonance imaging of the brain revealed multiple asymptomatic intracranial tuberculomas. Even after further treatment with antituberculous chemotherapy was initiated, the lesion failed to respond. The authors performed a laminectomy and excised the en plaque intradural extramedullary lesion. The patient's condition responded well to this treatment. Although the appearance of intracranial tuberculoma as a paradoxical response to chemotherapy has been previously reported, no authors have reported on the development of an extensive en plaque intradural extramedullary tuberculoma in conjunction with asymptomatic multiple intracranial tuberculomas as a paradoxical response. In cases in which patients present with compressive myelopathy following therapy for tuberculous meningitis, it is important to consider in the differential diagnosis that intradural extramedullary tuberculoma may be a paradoxical response to chemotherapy. The authors' experience and their review of the literature indicate that surgery has a definitive role to play in the management of spinal intradural extramedullary tuberculoma.
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26
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Luo L, Pino J. An intradural extramedullary tuberculoma of the spinal cord in a non-HIV-infected patient: case report and review of the literature. Lung 2006; 184:187-93. [PMID: 16902844 DOI: 10.1007/s00408-005-2579-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2005] [Indexed: 10/24/2022]
Abstract
Spinal tuberculomas are extrapulmonary manifestations of tuberculosis involving the central nervous system. They are characterized as extradural, intradural extramedullary, or intradural, according to their location. Intradural extramedullary tuberculomas are extremely rare. There have been only 24 case reports found in English language literature. Our case is the only documented intradural extramedullary tuberculoma in a non-HIV-infected patient in North America. A literature review using a Medline search from 1966 to the present is performed to characterize the clinical spectrum of the three types of tuberculomas and review the diagnosis and management of this potentially curable disease. An analysis of the cases of intradural extramedullary tuberculomas published since 1984 is performed to highlight the unique characteristics of this rare disease.
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Affiliation(s)
- Lan Luo
- Department of Internal Medicine, Coastal AHEC, University of North Carolina School of Medicine, 2131 South 17th Street, Wilmington, NC 28409, USA.
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27
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Muthukumar N, Venkatesh G, Senthilbabu S, Rajbaskar R. Surgery for intramedullary tuberculoma of the spinal cord: report of 2 cases. ACTA ACUST UNITED AC 2006; 66:69-74; discussion 74. [PMID: 16793447 DOI: 10.1016/j.surneu.2005.10.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2005] [Accepted: 10/22/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND Intramedullary tuberculomas are rare. With the widespread availability of MRI and the increasing incidence of HIV and HIV-related tuberculous infections, the incidence of these lesions is likely to increase worldwide. The role of medical and surgical treatment of these relatively rare lesions remains to be defined. We report 2 patients who presented with intramedullary tuberculomas and discuss the importance of early surgery in this condition. CASE DESCRIPTION Two female patients presented with insidious onset of myelopathy. The first patient had seizures due to imaging-documented intracranial tuberculomata and progressive paraparesis due to an intramedullary tuberculoma. The second patient had also had insidious onset of myelopathy and evidence of an intramedullary tuberculoma in MRI. She was also found to have abdominal and pulmonary tuberculosis. In view of the presence of tuberculosis elsewhere in the body in both the patients and the classical imaging features of intramedullary tuberculoma, they were treated initially with antituberculous chemotherapy. However, despite chemotherapy, both patients did not show improvement. Subsequently, both patients underwent microsurgical removal of the intramedullary lesions. The first patient who was neurologically well preserved at the time of surgery improved, whereas the second patient who was paraplegic with sphincter disturbances did not show any improvement. CONCLUSIONS These case reports are presented to highlight the role of early surgery in patients with profound neurological deficits and intramedullary tuberculoma even if the radiological appearance of the lesion is characteristic. Even in lesions that are potentially curable by chemotherapy, early surgery has an important role in the treatment.
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28
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Sree Harsha CK, Shetty AP, Rajasekaran S. Intradural spinal tuberculosis in the absence of vertebral or meningeal tuberculosis: a case report. J Orthop Surg (Hong Kong) 2006; 14:71-5. [PMID: 16598092 DOI: 10.1177/230949900601400116] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We present a patient with spinal intradural tuberculosis in the absence of both vertebral and meningeal tuberculosis. Diagnosis was made based on intra-operative findings and was confirmed by histopathology. Early surgical decompression along with a combination of steroid and antitubercular therapy resulted in a good outcome. At 26-month follow-up, the patient regained bladder control and was able to walk with support. Clinical features, magnetic resonance imaging, and intra-operative findings are described. Pathology and the relevant literature are discussed.
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Affiliation(s)
- C K Sree Harsha
- Department of Orthopaedics and Spinal Surgery, Ganga Hospital, Coimbatore, South India
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29
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Belahsen MF, Maaroufi M, Messouak O, Sqalli N, Tizniti S. Arachnoïdite spinale tuberculeuse avec tuberculomes intraduraux extramedullaires. J Neuroradiol 2006; 33:140-3. [PMID: 16733431 DOI: 10.1016/s0150-9861(06)77249-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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30
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Abstract
A previously healthy, HIV-negative, 40-year-old man presented with a 2-month history of progressive weakness of his left arm. Magnetic resonance imaging revealed an intradural, extramedullary plaque-shaped lesion at C6-T1 levels with high contrast enhancement. Based on the patient's clinical and radiologic findings, it was believed that the patient had an en plaque meningioma, and he was operated on. Histologic examination of the mass revealed granulomas with multinucleated and Langhans-type giant cells, typical of a tuberculoma. Intradural extramedullary tuberculomas should be considered in the differential diagnosis of en plaque meningioma as a rare entity.
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Affiliation(s)
- Hasan Mirzai
- Department of Neurosurgery, Celal Bayar University School of Medicine, Manisa, Turkey.
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31
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Roca B. Intradural extramedullary tuberculoma of the spinal cord: a review of reported cases. J Infect 2005; 50:425-31. [PMID: 15907551 DOI: 10.1016/j.jinf.2004.07.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2004] [Accepted: 07/19/2004] [Indexed: 10/26/2022]
Abstract
Intradural extramedullary tuberculoma of the spinal cord (IETSC) is a rare modality of tuberculosis, with only a few cases described so far. Here we review 22 reports of the disease found in the literature of the last 25 years. IETSC is closely associated with tuberculous meningitis (TM). Both conditions may occur simultaneously, but more frequently IETSC is preceded by TM. IETSC has been described in a predominantly young population of both genders. The pathogenesis is unknown, although a paradoxical reaction to antituberculous medication is a reasonable possibility. The disease presents insidiously with paraparesis, hypoesthesia with a sensory level, and bladder dysfunction, due to cord involvement or compression by the inflammatory process. Permanent paraparesis is a common sequela. MRI is the diagnostic technique of choice in IETSC. Prompt surgical excision of the tuberculoma is the cornerstone of therapy. Antituberculous treatment is also indicated; unless resistance is present, conventional chemotherapy is probably enough. Corticosteroids are also generally recommended. In conclusion, IETSC is a rare complication of TM, which presents insidiously, despite adequate antituberculous treatment. To avoid the permanent disability that this condition may provoke, an early diagnosis and prompt treatment is critical.
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Affiliation(s)
- Bernardino Roca
- Infectious Disease Division, Department of Medicine, Hospital General of Castellon, Castellon, Spain.
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Roca B, Gonzalez-Darder JM, Lucas A, Borras JM, Pesudo JV. Spinal cord compression from intradural extramedullary tuberculoma. Am J Med 2004; 117:620-1. [PMID: 15465517 DOI: 10.1016/j.amjmed.2004.06.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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