1
|
Shree R, Mahesh KV, Takkar A, Modi M, Goyal MK, Lal V. The Neuro-Ophthalmology of Tuberculosis. Neuroophthalmology 2023; 48:73-92. [PMID: 38487360 PMCID: PMC10936603 DOI: 10.1080/01658107.2023.2281435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/26/2023] [Indexed: 03/17/2024] Open
Abstract
Tuberculosis (TB) is a global health concern and central nervous system (CNS) TB leads to high mortality and morbidity. CNS TB can manifest as tubercular meningitis, tuberculoma, myelitis, and arachnoiditis. Neuro-ophthalmological involvement by TB can lead to permanent blindness, ocular nerve palsies and gaze restriction. Visual impairment is a dreaded complication of tubercular meningitis (TBM), which can result from visual pathway involvement at different levels with varying pathogenesis. Efferent pathway involvement includes cranial nerve palsies and disorders of gaze. The purpose of this review is to outline the various neuro-ophthalmological manifestations of TB along with a description of their unique pathogenesis and management. Optochiasmatic arachnoiditis and tuberculomas are the most common causes of vision loss followed by chronic papilloedema. Abducens nerve palsy is the most commonly seen ocular nerve palsy in TBM. Gaze palsies with deficits in saccades and pursuits can occur due to brainstem tuberculomas. Corticosteroids are the cornerstone in the management of paradoxical reactions, but other immunomodulators such as thalidomide and infliximab are being explored. Toxic optic neuropathy caused by ethambutol necessitates careful monitoring and immediate drug discontinuation. Cerebrospinal fluid diversion through ventriculo-peritoneal shunting may be required in patients with hydrocephalus in stage I and II of TBM to prevent visual impairment. Early diagnosis and prompt management are crucial to prevent permanent disability. Prevention strategies, public health initiatives, regular follow-up and timely intervention are essential in reducing the burden of CNS TB and its neuro-ophthalmological complications.
Collapse
Affiliation(s)
- Ritu Shree
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Karthik V. Mahesh
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Aastha Takkar
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Manish Modi
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Manoj K. Goyal
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vivek Lal
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| |
Collapse
|
2
|
Park YJ, Lee YJ, Jang JW, Yoo YJ. Cerebellar tuberculoma presenting as isolated skew deviation. Acta Neurol Belg 2023; 123:233-235. [PMID: 34089168 DOI: 10.1007/s13760-021-01718-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/22/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Young Joo Park
- Department of Ophthalmology, Kangwon National University School of Medicine, #156 Baengnyeong-ro, Chuncheon, 24289, South Korea
| | - Yeon Jeong Lee
- Department of Ophthalmology, Kangwon National University School of Medicine, #156 Baengnyeong-ro, Chuncheon, 24289, South Korea
| | - Jae-Won Jang
- Department of Neurology, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Yung-Ju Yoo
- Department of Ophthalmology, Kangwon National University School of Medicine, #156 Baengnyeong-ro, Chuncheon, 24289, South Korea.
| |
Collapse
|
3
|
Sankar J, Majumdar SS, Unniyal M, Singh H, Khullar A, Kumar K. Bilateral ptosis: An unusual presentation of mid brain tuberculoma. Med J Armed Forces India 2021; 77:96-100. [PMID: 33487874 DOI: 10.1016/j.mjafi.2018.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 12/26/2018] [Indexed: 11/28/2022] Open
Abstract
Central nervous system tuberculoma can have different clinical manifestations like headache, seizures, papilledema or other signs of raised intracranial pressure depending up on the site and number of tuberculoma. We report a case of 56 year old female reported with history of bilateral asymmetric ptosis of one month duration,with no other neurological defecit. Magnetic resonance imaging (MRI) brain revealed well defined ring enhancing lesion in the medial aspect of left hemi midbrain with diffuse disproportionate perilessional edema. Contrast Enhanced Computed Tomogram (CECT) of chest and abdomen revealed features of disseminated tuberculosis. She was diagnosed as a case of disseminated tuberculosis and started on antitubercular therapy with steroids and the ptosis almost resolved after 01 month of antitubercular therapy. Our case report is unique in the sense that only few cases of midbrain tuberculoma causing occulomotor abnormalities are reported in literature.
Collapse
Affiliation(s)
- J Sankar
- Graded Specialist (Medicine), Military Hospital Chennai, Tamilnadu, India
| | - S S Majumdar
- Graded Specialist (Medicine), Military Hospital Chennai, Tamilnadu, India
| | - Manish Unniyal
- Classified Specialist (Radiodiagnosis), Military Hospital Chennai, Tamilnadu, India
| | - Harmanpreet Singh
- Graded Specialist(Ophthalmology), Military Hospital Chennai, Tamilnadu, India
| | - Atul Khullar
- Commandant, Military Hospital Chennai, Tamilnadu, India
| | - Kishore Kumar
- Senior Advisor (Medicine&Oncology), Command Hospital (Air Force), Bengaluru, India
| |
Collapse
|
4
|
Sarkar S, Patra C, Dasgupta MK. Bilateral ptosis without upward gaze palsy: Unusual presentation of midbrain tuberculoma. J Neurosci Rural Pract 2019; 8:129-132. [PMID: 28149099 PMCID: PMC5225697 DOI: 10.4103/0976-3147.193526] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Central nervous system tuberculoma can have variable presentations depending on the site and number of tuberculomas. We are reporting a rare case of an 11-year-old male child presenting with ptosis and ataxia. Clinical examination revealed bilateral partial 3rd cranial nerve palsy (ptosis without any upward gaze palsy) associated with dysdiadochokinesia and ataxia on the right side. Magnetic resonance imaging of the brain revealed a single ring-enhancing lesion in the dorsal midbrain with perifocal edema. Magnetic resonance spectroscopy provided the etiological information as tuberculoma.
Collapse
Affiliation(s)
- Shatanik Sarkar
- Department of Pediatric Medicine, R. G. Kar Medical College and Hospital, Kolkata, West Bengal, India
| | - Chaitali Patra
- Department of Pediatric Medicine, Tapan Sinha Memorial Hospital, Kolkata, West Bengal, India
| | - Malay Kumar Dasgupta
- Department of Pediatric Medicine, R. G. Kar Medical College and Hospital, Kolkata, West Bengal, India
| |
Collapse
|
5
|
Kim JM, Lee HL, Im JH, Min SH, Nam TS, Lee SH. Selective Unidirectional Saccadic Palsy Due to Cavernous Angioma in the Pontine Tegmentum. J Clin Neurol 2019; 15:268-270. [PMID: 30877701 PMCID: PMC6444147 DOI: 10.3988/jcn.2019.15.2.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/07/2018] [Accepted: 12/10/2018] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jae-Myung Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Hak-Loh Lee
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Jae-Hwan Im
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Seong-Hyun Min
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Tai-Seung Nam
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Seung-Han Lee
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| |
Collapse
|
6
|
Kowsalya A, Gajarlewar U, Adulkar NG, Kumar SM. Unique case of midbrain tuberculoma presenting as isolated inferior rectus palsy with nystagmus. Indian J Ophthalmol 2018; 66:599-602. [PMID: 29582836 PMCID: PMC5892078 DOI: 10.4103/ijo.ijo_470_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Isolated brain stem tuberculoma constitutes about 5% of all intracranial tuberculomas. A case of isolated inferior rectus palsy with downbeat nystagmus due to presumed midbrain tuberculoma in an immunocompetent patient is described here. This report documents a rare entity of a combination of partial third nerve palsy with pupil involvement along with downbeat nystagmus.
Collapse
Affiliation(s)
- Akkayasamy Kowsalya
- Department of Neuro Ophthalmology, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - Umang Gajarlewar
- Department of Neuro Ophthalmology, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - Namrata G Adulkar
- Department of Neuro Ophthalmology, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - S Mahesh Kumar
- Department of Neuro Ophthalmology, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| |
Collapse
|
7
|
Sadashiva N, Tiwari S, Shukla D, Bhat D, Saini J, Somanna S, Devi BI. Isolated brainstem tuberculomas. Acta Neurochir (Wien) 2017; 159:889-897. [PMID: 28190145 DOI: 10.1007/s00701-017-3108-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 02/01/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Isolated brainstem tuberculomas are rare lesions and account for up to 5% of all intracranial tuberculomas in endemic areas. The difficulties in diagnosis and management of this condition are sparsely reported. The aim of this study is to illustrate the nuances in managing brainstem tuberculomas, define prognosis, and demonstrate a shift in management strategies with newer imaging modalities. METHOD A retrospective review of 14 patients diagnosed and treated with a diagnosis of 'isolated brainstem tuberculoma' between 2011 and 2015 was done. Diagnosis was made after combining the findings at clinical history, examination, as well as imaging features. Patients were treated with steroids for 6 weeks or until they made a meaningful clinical recovery, and antitubercular therapy (ATT) for a minimum of 18 months or until there was resolution of the tuberculoma. Confirmation of tubercular pathology was done by observing if response to treatment resulted in clinical improvement, which happened in all of our cases. RESULTS Mean age at diagnosis was 24.7 years and nine were males. Twelve patients had a combination of cranial nerve deficits with pyramidal weakness or sensory symptoms. Mean duration of symptoms was 4.7 months and tests for human immunodeficiency virus (HIV) infection were negative in all patients. Only two patients had a previous history of tubercular meningitis. Most lesions were located in the pons with size ranging from 1 to 22.2 cm3. Eight patients showed complete resolution of the lesion at latest follow-up and the rest were still on ATT. Mean duration of ATT received for resolution of the lesion was 22 months. Almost all of our patients improved clinically on steroids and ATT. CONCLUSIONS Intracranial tuberculomas may present with or without meningitis. A high index of suspicion is essential, especially in endemic areas. A combination of clinical symptoms, investigations, and imaging features help in coming to a diagnosis. Biopsy of a brainstem lesion is fraught with complications. Antitubercular therapy has a very good prognosis, though the duration of therapy required may be longer.
Collapse
Affiliation(s)
- Nishanth Sadashiva
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, 2nd Floor, Neurosciences Faculty Building, Bangalore, 560029, India
| | - Sarbesh Tiwari
- Department of Neuroimaging & Interventional Radiology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, 2nd Floor, Neurosciences Faculty Building, Bangalore, 560029, India
| | - Dhananjaya Bhat
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, 2nd Floor, Neurosciences Faculty Building, Bangalore, 560029, India
| | - Jitender Saini
- Department of Neuroimaging & Interventional Radiology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Sampath Somanna
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, 2nd Floor, Neurosciences Faculty Building, Bangalore, 560029, India
| | - Bhagavatula Indira Devi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, 2nd Floor, Neurosciences Faculty Building, Bangalore, 560029, India.
| |
Collapse
|
8
|
Agu CC, Aina O, Basunia M, Bhattarai B, Oke V, Schmidt MF, Quist J, Enriquez D, Gayam V. Right Gaze Palsy and Hoarseness: A Rare Presentation of Mediastinal Tuberculosis with an Isolated Prepontine Cistern Tuberculoma. Case Rep Infect Dis 2015; 2015:718289. [PMID: 26693365 PMCID: PMC4677012 DOI: 10.1155/2015/718289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 11/13/2015] [Accepted: 11/16/2015] [Indexed: 12/21/2022] Open
Abstract
We describe a previously healthy young man who presented with headaches, diplopia with right lateral gaze palsy, dysphagia, and hoarseness over a 2-month period. Magnetic resonance imaging of the brain revealed a small enhancing mass at the prepontine cistern and chest CT showed a left mediastinal mass. Mediastinoscopy and lymph node biopsy were performed. DNA probe and culture of the biopsy specimen were confirmed to be Mycobacterium tuberculosis complex. Resolution of neurologic symptoms was noted after 6 weeks, in addition to regression of brain stem and mediastinal lesions after 12 weeks of antituberculous therapy.
Collapse
Affiliation(s)
| | | | - Md Basunia
- Interfaith Medical Center, Brooklyn, NY, USA
| | | | - Vikram Oke
- Interfaith Medical Center, Brooklyn, NY, USA
| | | | | | | | - Vijay Gayam
- Interfaith Medical Center, Brooklyn, NY, USA
| |
Collapse
|
9
|
Gottlieb M, Kogan A, Kimball D. Intracranial tuberculoma presenting as an isolated oculomotor nerve paresis. J Emerg Med 2014; 48:e1-4. [PMID: 25453863 DOI: 10.1016/j.jemermed.2014.09.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 07/29/2014] [Accepted: 09/30/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND The differential diagnosis of isolated oculomotor nerve paresis ranges from benign to potentially lethal pathologies. Intracranial tuberculosis (TB), as in the case of this patient, carries a high morbidity and mortality. Early diagnosis is crucial to improve patient outcomes. CASE REPORT We present the case of a 46-year-old man with a chief complaint of 5 days of diplopia. His examination was remarkable for right inferolateral exotropia and weakness of the right medial rectus. Due to the neurologic findings, we obtained a computed tomography brain scan, which revealed a ring-enhancing lesion within the central midbrain with vasogenic edema causing mass effect on the cerebral aqueduct. Further evaluation revealed tuberculosis (TB) as the underlying etiology. He was placed on steroids and a four-drug anti-TB regimen with resultant improvement of his symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Intracranial tuberculoma can present with an isolated oculomotor nerve paresis in the absence of pulmonary or systemic symptoms. This case emphasizes the importance of maintaining a broad differential when investigating isolated oculomotor nerve paresis.
Collapse
Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Cook County Hospital, Chicago, Illinois
| | - Alexander Kogan
- Department of Emergency Medicine, Cook County Hospital, Chicago, Illinois
| | - Deborah Kimball
- Department of Emergency Medicine, Cook County Hospital, Chicago, Illinois
| |
Collapse
|
10
|
Gharai S, Venkatesh P, Sinha A, Garg S, Ghosh P. Isolated homonymous hemianopsia due to presumptive cerebral tubercular abscess as the initial manifestation of human immunodeficiency virus infection. Indian J Ophthalmol 2013; 60:321-4. [PMID: 22824606 PMCID: PMC3442472 DOI: 10.4103/0301-4738.98719] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a case of isolated homonymous hemianopsia due to presumptive cerebral tubercular abscess as the initial manifestation of human immunodeficiency virus (HIV) infection. A 30-year-old man presented to our outpatient department with sudden loss of visibility in his left visual field. He had no other systemic symptoms. Perimetry showed left-sided incongruous homonymous hemianopsia denser above the horizontal meridian. Magnetic resonance imaging revealed irregular well-marginated lobulated lesions right temporo-occipital cerebral hemisphere and left high fronto-parietal cerebral hemisphere suggestive of brain tubercular abscess. Serological tests for HIV were reactive, and the patient was started only on anti-tubercular drugs with the presumptive diagnosis of cerebral tubercular abscess. Therapeutic response confirmed the diagnosis. Atypical ophthalmic manifestations may be the initial presenting feature in patients with HIV infection. This highlights the need for increased index of suspicion for HIV infection in young patients with atypical ophthalmic manifestations.
Collapse
Affiliation(s)
- Sujit Gharai
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | | | | | | | | |
Collapse
|
11
|
Tuberculoma of the brain with unknown primary infection in an immunocompetent host. J Clin Neurosci 2012; 19:1320-2. [DOI: 10.1016/j.jocn.2011.12.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 12/17/2011] [Indexed: 11/18/2022]
|
12
|
Anhelation due to formation of tuberculomas at the medulla oblongata during chemotherapy of tuberculous meningitis. Neurol Neurochir Pol 2012; 46:501-5. [DOI: 10.5114/ninp.2012.31363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
13
|
Medulla oblongata tuberculoma mimicking metastasis presenting with stroke-like symptoms. Neurol Sci 2009; 30:349-52. [DOI: 10.1007/s10072-009-0099-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Accepted: 05/06/2009] [Indexed: 10/20/2022]
|