Intracranial tuberculoma in children: a new look at an old problem

Sellar-suprasellar tuberculomas in children: 2 cases and literature review

Sellar and suprasellar tuberculomas are rare. Patients with these lesions usually experience headache, vomiting, and hypofunction of pituitary gland; imaging reveals an enhancing sellar-suprasellar mass. We report 2 rare cases of sellar-suprasellar tuberculomas in children aged 8 and 6 years. One child presented with features of headache and vomiting, and the other presented with posterior pituitary dysfunction. In both cases, imaging revealed sellar-suprasellar masses. Both cases were multidrug-resistant tuberculomas. We discuss sellar-suprasellar tuberculomas, a rare form of neurotuberculosis in the background of an overall increase in multidrug-resistant tuberculosis, especially in children.

Multiple intracranial tuberculomas mimicking granulocytic sarcomas in acute myeloid leukemia

The diagnosis of incracranial tuberculoma in immune-compromised hosts is often difficult because conventional magnetic resonance (MR) imaging of tuberculoma reveals various findings and neurologic symptoms are not typical. Here, we report a case of a 54-yr old man with multiple intracranial tuberculoma who was treated for acute myeloid leukemia. He complained of right-side paresthesia after the third consolidation chemotherapy without leukemic relapse and fever. MR imaging of the brain showed multiple ring-enhanced lesions in the cerebrum, cerebellar hemisphere, and pons. The lesions appeared to mimic a metastatic tumor or abscess. Cerebrospinal fluid analysis showed no abnormal cells, but the level of adenosine deaminase was elevated (28.8 IU/L, normal 0-8). Stereotactic brain biopsy was performed, but only reactive gliosis was observed. To confirm diagnosis, an open brain biopsy was performed. The histopathology demonstrated chronic granulomatous inflammation with caseous necrosis. Tuberculous-polymerase chain reaction of the biopsy showed a positive result. He was treated with anti-tuberculosis medication and a high dose of steroid. Paresthesia improved, and follow-up brain MR imaging showed the decreased size and numbers of ring-enhanced lesions and improvement of perilesional edema 1 month after treatment. Here, we report on an interesting case of intracranial tuberculoma in acute myeloid leukemia.

Surgical management and outcome of tuberculous atlantoaxial dislocation: a 15-year experience

OBJECTIVE

Tuberculous atlantoaxial dislocation is a rare disease entity. However, tuberculosis continues to be endemic in developing countries. Its earliest clinical presentation may be nonspecific, and delay in diagnosis may lead to irreversible neurological deficit. The management of tuberculous atlantoaxial dislocation includes ventral cervicomedullary decompression, occipitocervical arthrodesis, and administration of antituberculous medications.

METHODS

Eighteen patients with tuberculous atlantoaxial dislocation who presented with neck pain and/or occipital headache, restriction of neck movement, difficulty swallowing, and signs of myelopathy were studied. Four patients had evidence of associated pulmonary tuberculosis. Plain x-rays of the cervical spine, computed tomographic scans, and magnetic resonance images were obtained in all patients for diagnosis and to assess the degree of dislocation and cervicomedullary compression. Simultaneous anterior neural decompression, via a transcervical retropharyngeal approach, and posterior arthrodesis were performed on all patients while they remained under anesthesia. Antituberculous chemotherapy was continued for 18 months.

RESULTS

Histopathological analysis of excised tissue was consistent with tuberculosis in all patients. However, Ziehl-Neelsen staining for acid-fast bacilli was positive in two cases, and culture for Mycobacterium tuberculosis was negative in all patients. Patients with severe myelopathy experienced marked improvement. One patient died of fulminant resistant tuberculous meningitis.

CONCLUSION

The transcervical retropharyngeal approach to the craniovertebral junction provides direct access to the lesion and avoids the potential bacterial contamination of the oral and pharyngeal cavity. It also prevents the development of persistent fistulae. Posterior stabilization should be performed directly after anterior neural decompression, while the patient remains under anesthesia, to prevent neurological deterioration before subsequent posterior fixation. This technique also is helpful for early mobilization of patients. The aim of surgical treatment should be to obtain biopsy tissue and to perform radical excision of epidural granulation tissue/abscess and infected bone using microsurgical technique. Antituberculous medication must be continued for 18 months with four drug regimens, and continuous monitoring of drug toxicity should be performed throughout the course of treatment.

Tuberculosis of the central nervous system in children

Tuberculosis remains one of the most common and important infectious diseases in the world. Between 1% and 2% of children with untreated tuberculosis infection will develop tuberculous meningitis. In 1997, 186 cases of tuberculous meningitis were reported in the United States. The initial clinical manifestations of tuberculous meningitis are protean, making early disease difficult to recognize. The clinical and radiographic manifestations of tuberculous meningitis result from the combination of basilar meningitis, infarction, and vasculitis. Early diagnosis can be problematic as Mycobacterium tuberculosis is difficult to detect by rapid tests. Although the response to antituberculosis chemotherapy is generally favorable, complications commonly occur, particularly if the diagnosis is delayed. With appropriate public health management of known tuberculosis cases, cases of CNS tuberculosis in children can be prevented.

Tuberculoma presenting as an en plaque meningioma. Case report

Intracranial tuberculomas generally present as either solitary or multiple lesions in the brain parenchyma. They are characterized by a ring-enhancing area on either computerized tomography scans or magnetic resonance images. A case is presented in which an intracranial tuberculoma was dural based and had an appearance similar to an en plaque meningioma.

Clinical and public health aspects of tuberculous meningitis in children

To define the clinical and public health aspects of tuberculous meningitis, we conducted a 10-year retrospective review of patients with central nervous system (CNS) tuberculosis, investigated health department records of contact investigations involving our patients, and assessed prospective follow-up of patients. Thirty-one cases of CNS tuberculosis (8.6% of all pediatric patients with tuberculosis) were reviewed. Three patients had tuberculomas, 23 had meningitis, and five had both. Cranial nerve involvement, basilar meningitis, and hydrocephalus were common clinical and radiographic findings. Sixty-eight percent had been examined by a physician in the preceding month, and 13% had been hospitalized. Symptoms related to tuberculosis averaged 17 days before admission. For 15 patients (47%) there was no initial family history of tuberculosis, but an adult with tuberculosis was discovered after the child's symptoms became evident. Tuberculosis had been diagnosed in an adult in close contact with nine of the patients (38%) before the child became ill. Eight of these adult source cases already had been reported to the health department, and more rapid examination of contacts may have prevented meningeal tuberculosis in the child. The diagnosis of CNS tuberculosis should be considered in all children with neurologic signs and symptoms of, and risk factors for, tuberculosis.

Role of surgery in tuberculous mastoiditis

A study was undertaken in 43 patients to determine the role of surgery in tuberculous mastoiditis. Cortical mastoidectomy was performed on five patients (Group I). Incision and drainage of a post-auricular abscess, removal of sequestrum and meatoplasty in eight (Group II). Thirty patients had no ear surgery (Group III). Of the 17 patients with facial palsy, three were in Group I, two in Group II, 12 in Group III. The patients in all three groups were treated with anti-tuberculous drugs for a period of no less than six months. The average time taken for the otorrhoea to subside and granulation tissue to resolve completely was two months in all three groups. The facial nerve recovery in the non-operated ears (Group III) was 92 per cent and in the operated ears (Group I and II) 80 per cent. The conclusion is that chemotherapy is the management of choice in tuberculous mastoiditis. The only role of surgery is incision and drainage of a post-auricular abscess and removal of sequestrum if present.

Central nervous system tuberculosis in children

The incidence of tuberculosis in the United States is increasing in all age groups; 5% of all of these patients have central nervous system involvement. We studied childhood central nervous system tuberculosis between 1979 and 1989 and reviewed the literature for patients up to 14 years of age. The small number of patients reported in this country results in delayed diagnoses because of reduced awareness. Cranial computed tomography within 1 week of initial symptoms may reveal basilar enhancement, hydrocephalus, or infarction. When combined with cerebrospinal fluid findings atypical for common bacterial infection, these radiographic findings support the prompt initiation of antituberculous therapy. Prophylactic considerations are also discussed.

Intracranial tuberculosis in children: CT appearance and clinical outcome

We retrospectively evaluated the CT studies of 9 children who presented with intracranial tuberculosis during 1981-1987, and compared their radiographic appearance with the clinical outcome. The most common radiographic findings were: 1) ventriculomegaly (7/9) ,2) tuberculoma formation (6/9), and 3) infarction (4/9). Of 7 patients with ventriculomegaly, 3 required a ventricular shunt and 2 had spontaneous resolution of ventricular dilatation. Four children with ventriculomegaly were moderately or severely retarded, one had cognitive dysfunction, and one was neurologically normal. Four of six children with tuberculoma also had infarction and/or ventriculomegaly; of these four children, three were moderately or severely retarded. Two patients with tuberculoma as the only intracranial abnormality had complete resolution of the granuloma with normal neurologic outcome following antituberculous therapy. The four children with large vessel infarction also had ventriculomegaly; three had poor clinical outcome. The presence of tuberculoma alone is not necessarily predictive of poor neurologic outcome; age less than 20 months, infarct, and/or ventriculomegaly are usually associated with sequelae.