[Extramedullary intradural tuberculosis: a case report and review of the literature]

INTRODUCTION

Central nervous system tuberculosis is a common chronic infection in developing countries, being the most frequent forms: tuberculous meningitis and intracranial tuberculosis. Extramedullary intradural tuberculosis is a rare entity with few cases described in the world literature, and is usually associated with a history of tuberculous meningitis or during antituberculosis treatment.

CASE REPORT

A 17 years-old male patient, without history of tuberculosis, with subacute onset and progressive course of compressive myelopathy. Spinal magnetic resonance imaging revealed an intradural extramedullary mass lesion between the C4 and T8 spinal levels. Surgical resection of tuberculoma was realized, followed by chemotherapy. The histopathological study confirmed the diagnostic.

CONCLUSIONS

Tuberculosis of the central nervous system is an entity of high incidence in developing countries, and intradural extramedullary tuberculoma should be included in the differential diagnosis of expansive spinal cord injuries, especially if the patient is young and there is a history of pulmonary tuberculosis or tuberculous meningitis. It is also important to take it into account as part of a paradoxical reaction after the initiation of specific treatment. Although surgical resection improves compressive medullary symptoms, medical therapy remains the mainstay in the treatment of tuberculomas.

Successful Management of Tubercular Subretinal Granulomas

PURPOSE

To report the successful management of 12 eyes of 11 patients with tubercular subretinal granulomas.

METHODS

Eleven consecutive patients with a presumed or confirmed diagnosis of tubercular subretinal granulomas were treated with four-drug anti-tuberculosis chemotherapy with concomitant oral corticosteroids. Two patients underwent pars plana vitrectomy.

RESULTS

The study included seven males and four women with a median age of 30.5 years. Ten eyes responded well to medical management and a final visual acuity of 20/80 or better was achieved in eight of them. The eyes subjected to pars plana vitrectomy had a relatively worse outcome.

CONCLUSIONS

Tubercular subretinal granulomas are amenable to medical management provided an early diagnosis is made and treatment is initiated promptly. Once the diagnosis of presumed or confirmed tuberculosis is established, surgical intervention should be avoided.

Treatment of intraspinal tuberculoma

Neurological manifestations in spinal tuberculosis often occur secondary to vertebral involvement. However, tuberculoma of the spinal cord or extradural granuloma without radiological evidence of vertebral involvement may be responsible for neurological complications. We report 22 patients with intraspinal tuberculoma (19 extradural, three intramedullary) ranging in age from 17 to 70 years. Three patients had a history of paraplegia of acute onset (within 12 hours of the appearance of neural deficit). Only four patients had spinal tenderness, and bone involvement could be seen on plain radiographs in only three patients. Extradural tubercular granuloma without vertebral involvement is uncommon. Of the 15 extradural tuberculoma patients who had a CT scan and/or MRI, only five had no osseous involvement. Laminectomy and surgical decompression was performed in all 19 patients with extradural granuloma. Thirteen patients showed complete neural recovery within 2 years. Of the three patients with intramedullary involvement, one underwent myelotomy and decompression and died within 2 months of surgery. The other two patients were treated nonoperatively with antitubercular therapy and showed complete neural recovery. All patients received antitubercular therapy for a minimum of 1 year. Intraspinal tubercular granuloma should be considered in the differential diagnosis when a case of spinal tumor syndrome is encountered in an endemic zone of tuberculosis.

Intradural extramedullary tuberculoma of the spinal cord: a review of reported cases

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.

Tuberculose du poignet

PURPOSE OF THE STUDY

We present our experience with a rare localization of tuberculosis, the wrist, focusing on symptoms and outcome after treatment.

MATERIAL AND METHODS

Our series included eleven patients, eight men and three women, mean age 42 Years, who presented tuberculosis of the wrist. Tuberculosis was known in four patients who were being treated and a context of tuberculosis was recognized in three others. One patient on long-term corticosteroid therapy was immunodepressed. Mean time from symptom onset to consultation was fifteen months indicating a slow and progressive disease process. An inflammatory syndrome was noted in nine patients. Based on the standard x-rays, the David-Chausse classification was: stage I n=1; stage II n=1; stage III n=3; stage IV n=4. The AP view of the wrist was normal in two patients. Diagnosis of tuberculosis was confirmed on the surgical biopsy specimen which revealed epithelio-gigantocellulary granuloma with caseous necrosis. In only five patients Koch bacilli developed in culture on Lowenstein-Jensen. Patients were given anti-tuberculous antibiotics and the wrist was immobilized in a plaster splint.

RESULTS

Mean follow-up was two years. The disease course was blunted by the antituberculosis treatment. Surgical drainage was only required to clear abscesses. Wrist stiffness was frequent and had a significant functional impact.

DISCUSSION

These eleven cases of a rare localization of tuberculosis illustrate the slow progressive course of clinical symptoms and radiological signs of tuberculosis, emphasizing the difficulties encountered in establishing early diagnosis of such isolated non-abscessed localizations. Anti-tuberculous treatment is effective but the functional outcome depends on early diagnosis before the development of radiological evidence of joint destruction.

Intradural, eextramedullary tuberculoma of the spinal cord as a complication of tuberculous meningitis

An unusual case of an intradural, extramedullary spinal cord tuberculoma, as a complication of tuberculous meningitis caused by a strain susceptible to major anti-TB drugs, is described in a previously healthy, HIV-negative, 27-year-old male. The tuberculoma was detected by magnetic resonance imaging (MRI) while the patient was under conventional anti-tuberculous (anti-TB) therapy. Histopathology confirmed the diagnosis. Despite the anti-TB treatment and the surgical resection, intramedullary spreading occurred. Finally, a favorable response was achieved by prolongation of treatment accompanied by the administration of ofloxacin and cycloserine.

[Treatment of patients with destructive pulmonary tuberculosis with concomitant diabetes mellitus]

Diabetes mellitus accompanying tuberculosis complicates the course of the latter and remains a topical problem of phthisiology. Surgical treatment of patient with both conditions presents a high risk and is employed unreasonably rarely. The results of medical (173 patients) and surgical (107 patients) treatments were studied in patients with destructive tuberculosis concurrent with diabetes mellitus. Analyzing early and late results of treatment showed a more steady-state effect in the group of surgically treated patients. Thus, surgery should be desirably used in all patients with preserving destructive changes after the basic course of antibacterial therapy.

[New treatment modalities for the cavitary lesion of drug-resistant tuberculous]

The reason for not obtaining any response to antituberculous treatment in drug-resistant tuberculous cases is the presence of the cavitary lesion. Because of the treatment difficulties in drug-resistant tuberculous (DRTb) and of the surgical complications, many new treatment modalities have been developed as an alternative intervention to surgical therapy. In this report, the use new methods such as laser, microwave and electrical field in DRTb was evaluated.

Spinal intramedullary tuberculoma and abscess: a rare cause of paraparesis

Five cases of spinal intramedullary tuberculomas (IMT) and one case of spinal intramedullary tuberculous abscess (ITA) are presented. Gd enhanced MRI revealed ring enhancing lesion with central hypodensity, suggesting granulomatous pathology. Surgical excision of the intramedullary lesions was carried out in four cases, while two patients received presumptive anti-tuberculous chemotherapy only. Repeat MRI after completion of anti-tuberculous therapy showed total resolution of the lesion. In other cases following surgical excision, the patients improved significantly. The management of these rare lesions is discussed and the literature reviewed.

Intrasellar tuberculoma--a difficult diagnosis

Tuberculosis is an exceptional cause of intrasellar mass lesion and diagnosis is usually established after histological examination following surgery. We report a 32-year-old woman with headache and amenorrhea, analytical features of hypopituitarism and an intrasellar mass lesion in radiological studies. A transsphenoidal approach was performed and tissue examination revealed pituitary tuberculoma. Additionally, we review the previously reported cases.

Intramedullary tuberculoma of the conus medullaris: case report and review of the literature

OBJECTIVE

To illustrate the dilemmas in the diagnosis and management of intramedullary tuberculomas of the spinal cord.

METHODS

Case report of a 32 year-old man with tuberculous meningitis. The presence of unexplained urinary retention and progressive weakness in the legs led to the discovery of an additional tuberculoma of the conus medullaris.

SETTING

Dicle University Diyarbakir, Turkey.

RESULTS

The patient was on a 1-year course of isoniazid, pyrazinamide and rifampicin, and responded well to conservative treatment. Our patient's unique features were represented by the worsening of neurological symptoms while being treated with adequate anti-tuberculous medication.

CONCLUSION

We present a case of intramedullary tuberculoma of the conus medullaris to illustrate the dilemmas in the diagnosis and management of this curable disease, and review of the literature to date.

Disseminated tuberculosis with ocular tuberculoma and disseminated candidiasis in acquired immunodeficiency syndrome

A 39 years man presented with painless progressive loss of vision and proptosis of left eye associated with constitutional symptoms. He was diagnosed to have acquired immunodeficiency syndrome (AIDS) with disseminated tuberculosis (TB) and invasive candidiasis. The proptosis was due to a retrobulbar mass. The uncommon occurrence of retrobulbar tuberculoma and invasive candidiasis is discussed and relevant literature is reviewed.

[Primary tuberculosis of the breast]

BACKGROUND

Despite generalized BCG vaccination, tuberculosis remains a public health issue in France. Breast localizations are exceptional and constitute a diagnostic and therapeutic challenge.

CASE REPORT

A 34-year-old woman who was nursing her 3-month old infant underwent emergency surgery for a breast abscess that had been incised one month earlier and treated with non-specific antibiotic therapy without success. All necrotic tissue was removed. Pathology provided the diagnosis of tuberculosis. An anti-tuberculosis regimen (INH + rifampicin + PZA + ethambutol for two months followed by INH + rifampicin for 7 months) was instituted. The epidemiology search was negative and no extension was found. The clinical course was favorable at 6 months.

DISCUSSION

Tuberculosis is rarely localized in the breast. The main differential diagnosis is breast cancer. Pathology examination is required for diagnosis. Anti-tuberculosis antibiotic therapy may be associated with surgery in case of extension.

Intramedullary spinal tuberculoma: a case report

STUDY DESIGN

A case report showing an intramedullary thoracic spinal tuberculoma secondary to pulmonary tuberculosis in a 16-year-old patient with findings of subacute spinal cord compression.

OBJECTIVES

The significance and the use of magnetic resonance imaging in the diagnosis of intramedullary tuberculoma, and the treatment of the patient that involves surgically the excision of intramedullary lesion followed by appropriate antituberculous therapy.

SUMMARY OF BACKGROUND DATA

Tuberculomas of spinal cord are rare entities. The possibility of intramedullary tuberculoma should be seriously considered when an intraspinal mass is found, provided that pulmonary tuberculosis is present in the history of the patient.

METHOD

Th4-Th5 laminectomy was performed. Intramedullary tuberculoma was excised through a myelotomy. Antituberculous treatment was applied after the surgery.

RESULTS

Excellent clinical outcome was obtained with a combination of both medical and surgical treatments.

CONCLUSION

The intramedullary spinal tuberculoma, although a rare entity, must be considered in the differential diagnosis of the spinal cord compression in patients with a history of tuberculosis, human immunodeficiency virus, and those who have a bad socioeconomic condition and bad nutrition habit. When confronted with a progressing neurologic deficit, a combination of microsurgical resection and antituberculous chemotherapy with the avoidance of steroids should be the choice of treatment for intramedullary tuberculomas.

[Precision surgery of tuberculoma in patients with diabetes mellitus]

Indications and contraindications for precisional excision of tuberculoma in patients with diabetes mellitus were adduced, the original method of its performance was elaborated. Organ-preserving operation was done in 25 patients. The precisional excision of tuberculoma have permitted to preserve healthy pulmonary parenchyma (the part--in 18 patients and the whole lung--in 3). In all the patients the ability to work was restored.

Intrasellar tuberculoma--an enigmatic pituitary infection: a series of 18 cases

OBJECTIVE

Intrasellar tuberculomas are rare and only few case reports have been described in the literature. We report a series of 18 cases of histologically proven intrasellar tuberculomas, which, to the best of our knowledge, is the largest series in the English literature.

METHODS

A total of 1143 pituitary lesions, between 1984 and June 1999, were operated for various reasons in our institute. Of these, 18 cases were histopathologically proven intrasellar tuberculomas. The clinical profile was reviewed in detail. Radiological data and histopathological slides were also reviewed.

RESULTS

The age ranged from 8 to 43 years (average 23.6 years) with a female preponderance. The duration of symptoms varied from 15 days to 2 years (average 4 months), the most common symptoms being headache followed by decrease or loss of vision. Five patients had features of pan-hypopituitarism whereas three had raised prolactin (PRL) levels. In six patients, both sella as well as sphenoid sinus were involved. In one patient the lesion was extending from the sella over the clivus. Clinically as well as radiologically, these lesions were mistaken for pituitary adenomas except for one case where tuberculoma was suspected on imaging. In three patients, there was past history of pulmonary tuberculosis, in one patient of tuberculous meningitis, and in one patient, of spondilytis of the spine. In one patient there was cervical lymphadenopathy along with features of acromegaly (also proved by high levels of serum growth hormone) and radiology revealed a pituitary pathology. Microscopic examination of the excised lesion revealed a composite lesion consisting of a pituitary adenoma and tuberculoma, which has not been documented in literature to date. One patient died during the hospital stay. All the other patients were put on antitubercular chemotherapy following surgery and had good outcomes.

CONCLUSION

Intrasellar tuberculomas are rare. These may be suspected in female patients especially if radiological imaging shows involvement of paranasal sinuses and pituitary fossa along with thickening of pituitary stalk. Simultaneous involvement of clivus may also be an additional feature. The incidence of pituitary tuberculosis is likely to increase with a rise in the incidence of AIDS.

Management strategies for peripheral tuberculous lymphadenopathy

OBJECTIVE

To assess the usual means for diagnosing peripheral tuberculous lymphadenitis and present our experience in the management of the disease.

METHODS

Three hundred and two patients with peripheral lymphadenopathy due to tuberculosis were diagnosed and referred by several hospitals in 9 governorates to the National Tuberculosis Institute. Patients were reviewed prospectively regarding diagnosis and treatment.

RESULTS

Histological findings were diagnostic in 94% of patients. In our experience, isolation of mycobacterium from the lymph node tissue was neither practical nor reliable. Four out of 54 patients with bulky caseating nodes or discharging sinuses failed to respond to chemotherapy after 2 months of treatment.

CONCLUSION

Histopathological diagnosis was the most practical method for diagnosing peripheral tuberculous lymphadenopathy. We recommend that patients who had bulky caseating nodes or discharging sinuses, to undergo surgical excision followed by chemotherapy.

Neuroimages of disseminated neurotuberculosis: report of one case

We report a 38-year-old male patient with rare concurrent intracranial and intramedullary tuberculoma demonstrated by serial magnetic resonance image (MRI) and confirmed by a pathological study. The involvement of the middle cerebral artery is also shown by magnetic resonance angiography. These findings have a good correlation with the clinical features including cranial nerve involvement, stroke-like symptoms, and paraplegia.

Intramedullary spinal tuberculoma presenting as a conus tumor: a case report and review of the literature

Intramedullary spinal tuberculoma is a rare form of central nervous system tuberculosis. Although tuberculosis is unusual in the west, it is still prevalent in Asia and Africa. We report a case in which the diagnosis was made histologically without evidence of symptoms of systemic tuberculosis. The lesion, located in the conus medullaris, mimicked a conus tumor. The patient was a 20-year-old man who presented with a history of progressive leg weakness, urinary urgency, and impotence. There was no history of, or recent contact with, tuberculosis. A diagnosis of an intramedullary tumor in the conus medullaris was made by MRI. The patient underwent a T11-L1 laminectomy and total resection of the lesion with microsurgical technique. Histologic examination revealed a granulomatous lesion containing Langhans' giant cells, inflammatory cells, and caseating necrosis. Antituberculous medication was instituted as soon as the diagnosis was made. Neurologic symptoms and signs slowly improved postoperatively. A combination of microsurgical resection and antituberculous chemotherapy should be the choice of treatment for intramedullary tuberculomas.

[Diagnosis and treatment of hepatic tuberculoma]

OBJECTIVE

To explore the appropriate diagnosis and treatment for hepatic tuberculoma.

METHOD

Eight cases with hepatic tuberculoma confirmed pathologically were reported and analyzed.

RESULTS

Five of the eight cases were misdiagnosed as other types of hepatic tumor, and only 3 cases correctly diagnosed preoperatively. All cases underwent segmentectomy or local resection, and no relapse was found after four-year follow-up in seven cases.

CONCLUSIONS

The cases with hepatic occupying-space lesions who had tuberculosis history should be suspected of being hepatic tuberculoma; The aspiration liver biopsy guided by B-mode ultrasound and CT scan can provide correct diagnosis; The segmentectomy and local resection are effective and practicable for treatment of hepatic tuberculoma, and the antituberculosis drugs should be administrated postoperatively so as to strengthen the therapeutic effect.

[A case of intracerebral tuberculoma resistant to therapy]

A 48-year-old woman complained of fever, headache and nausea in October, 1994. Because polymerase chain reaction (PCR) was positive for mycobacterium tuberculosis in her cerebrospinal fluid, she was administered anti-tuberculous drugs. Steroid hormone was also administered for her symptoms of intracranial hypertension. However, multiple intracerebral masses appeared on CT and MRI 2 months later, and have increased in number and size. Cessation of the steroid hormone was impossible as her intracranial hypertension had been deteriorated. She was transferred to our clinic on October 23, 1995. On neurological examination she was drowsy and showed papilledema, weakness of bilateral lower extremities, left cerebellar sign, and bilateral Babinski's reflexes. Enhanced CT and MRI revealed multi-locular lesions in the right fronto-temporal, left temporal and left cerebellar regions. On November 7, 1995 she was operated on. Right fronto-temporal and left cerebellar masses were partially removed. Pathological examination and PCR of the surgical specimens demonstrated tuberculoma. Postoperatively, her consciousness disturbance improved and the residual tuberculomas decreased in size under the influence of anti-tuberculous drugs and cessation of the use of steroid hormone. Recently, tuberculosis is common neither in Japan nor in Western countries. Intracerebral tuberculoma is also very rare. The tuberculosis in our patient with multiple intracerebral tuberculomas resistant to antituberculous drugs was thought to have been induced by decreased resistance to the infection due to the administration of the steroid hormone.

Intramedullary tuberculoma: report of two cases with MRI findings

Two cases of spinal intramedullary tuberculous granulomas (tuberculomas) without any bony involvement are reported. The rarity of the occurrence and the magnetic resonance imaging (MRI) findings are discussed. Microsurgical excision and antituberculous treatment produced good results.

Spinal tuberculosis: a diagnostic and management challenge

The authors reviewed 29 cases of spinal tuberculosis treated from 1973 to 1993 with an average follow-up time of 7.4 years. Clinical findings included back pain, paraparesis, kyphosis, fever, sensory disturbance, and bowel and bladder dysfunction. Twenty-two patients (76%) presented with neurological deficit; 12 (41%) were initially misdiagnosed. Sixteen patients (55%) had predominant vertebral body involvement; nine had marked bone collapse with neurological compromise. Eleven individuals (39%) had intraspinal granulomatous tissue causing neurological dysfunction in the absence of bone destruction, and two (7%) had intramedullary tuberculomas. All patients received antituberculous medications: 13 were initially treated with bracing alone, eight underwent laminectomy and debridement of extra- or intradural granulomatous tissue, and eight underwent anterior, posterior, or combined fusion procedures. No patient with neurological deficit recovered or stabilized with nonoperative management. Thirteen patients were readmitted with progression of inadequately treated osteomyelitis; 12 (92%) of these required new or more radical fusion procedures. Anterior fusion failure was associated with marked preoperative kyphosis and multilevel disease requiring a graft that spanned more than two disc spaces. Courses of antibiotic medications shorter than 6 months were invariably associated with disease recurrence. It was concluded that 1) patients should receive at least 12 months of appropriate antituberculous therapy; 2) individuals with neurological deficit should undergo surgical decompression; 3) laminectomy and debridement are adequate for intraspinal granulomatous tissue in the absence of significant bone destruction; 4) when vertebral body involvement has produced wedging and kyphosis, aggressive debridement and fusion are indicated to prevent delayed instability and progression of disease.

Tuberculoma of the mastoid

Tuberculoma is a rare but known complication of tuberculosis. It rarely occurs in the mastoid bone. When it occurs in the middle ear cleft, it can lead to intracranial complications if there is a delay in the diagnosis and management. A rare case of tuberculosis of the middle ear cleft which presented as tuberculoma of the mastoid bone with infranuclear facial palsy is described. The tuberculoma was removed and a canal wall down tympanomastoidectomy was performed. Post-operatively the patient was kept on antituberculous therapy. The various problems encountered in the diagnosis and management of this case are discussed.

[Tuberculous lesions of the pleura]

Tuberculous involvement of the pleura became quite incident of late. Eighty-seven patients with this condition were hospitalized at the phthisiosurgery department of the Kostroma District Antituberculosis Center in 1985-1992. Tuberculous pleurisy was diagnosed in 30 patients, in 29 pleurisy was a complication of pulmonary tuberculosis (in 13 cases of infiltrative tuberculosis, in 12 of focal, in 3 of disseminated, and in 1 of cirrhotic pulmonary tuberculosis), in 8 patients acute tuberculous pleural empyema was diagnosed which developed in the presence of infiltrative and cirrhotic pulmonary tuberculosis, and in 18 cases chronic tuberculous pleural empyema with calcification was found. Two patients were operated on for pleural tuberculomas. Tuberculous pleurisy can be completely cured with drugs and therefore presents not a therapeutic but a diagnostic problem. In intricate cases wider use of invasive methods of examination may be recommended, such as puncture biopsy of the pleura, thoracoscopy with spot biopsy of the pleura, open biopsy of the pleura, and biopsy of peristernal lymph nodes.

Tuberculosis of the parotid salivary gland

An interesting and rare case of tuberculosis involving a parotid gland is discussed. Although pulmonary tuberculosis is not uncommon in Turkey, primary parotid gland involvement is rare. The patient was treated by parotidectomy and antituberculous chemotherapy.

Brain-stem tuberculoma. An analysis of 11 patients

The clinical and radiologic findings in 11 patients with brain-stem tuberculoma were reviewed. Clinical manifestations included various combinations of focal signs and symptoms of subacute onset, similar to those produced by other space-occupying lesions of the brain stem. Evidence of systemic tuberculosis was found in six cases (55%). Computed tomography (CT) usually showed an isodense or hyperdense brain-stem mass with abnormal contrast enhancement; associated supratentorial granulomas were found in four cases, and hydrocephalus was found in two cases. Magnetic resonance imaging showed irregular brain-stem lesions with long T1 and short T2 relaxation times. Cerebrospinal fluid findings were also nonspecific, as smears for acid-fast bacilli were most often negative. An incorrect diagnosis of pontine glioma was made in one patient. In contrast, proper integration of data from CT and magnetic resonance imaging findings, cerebrospinal fluid analysis, and x-ray films of the chest permitted an accurate diagnosis in ten cases. Prompt therapy with antituberculous drugs resulted in clinical improvement, documented by CT, in most patients. Brain-stem tuberculoma should be suspected in patients with space-occupying lesions of the brain stem who live in geographic areas where tuberculosis is endemic. Early diagnosis and prompt medical therapy are important in preventing mortality and reducing morbidity.

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

Intracranial tuberculoma has become a rare cause of space-occupying intracranial lesions in childhood, but it must still be considered in the differential diagnosis. Tuberculosis remains a significant disease in developing countries and in the United States, and tuberculoma is a well known presentation of childhood tuberculosis. This diagnosis must be considered especially in persons traveling or living in developing countries and in immigrants from third-world areas. We report three cases of tuberculoma in children seen during one year at our institutions to illustrate the need for continued suspicion. We summarize the clinical presentation and current treatment recommendations and review the available literature.

Management of intracranial tuberculoma in children

Thirty-one patients were studied during a period of 3 years in order to identify features helpful for the diagnosis of tuberculoma. Sixteen had a history of pyrexia, 4 had had contact with cases of tuberculosis, the tuberculin test was positive in 15, the erythrocyte sedimentation rate (ESR) was elevated in 23, and 5 had concomitant tuberculous infections. Three had multiple lesions and 10 showed CT scan features suggestive of tuberculoma. Nineteen patients were successfully treated with drugs alone; seven needed surgery because they failed to respond to drugs clinically or because CT indicated no improvement. One patient proved to have a tumor, having shown an absence of response to drugs; four were operated on without drug trial because they were thought to have a tumor, and 1 needed surgery because of the mass effect of a very large tuberculoma. Infratentorial lesions associated with hydrocephalus were treated with ventriculoperitoneal shunts.

Changing concepts in the treatment of tuberculomas of the brain

Tuberculomas of the brain in children constitute 5% to 8% of intracranial space-occupying lesions in developing countries. These have in the past been treated with antituberculous drugs and with excision of large masses when the intracranial tension was high. Computed tomography (CT) has modified this approach. CT has resulted in earlier diagnosis and has been of help in monitoring the results of medical treatment of tuberculomas in children. With such monitoring there has been less need for surgical excision. At the same time, it has been realised that some caution is required towards our dependence on CT, as the image morphology of a tuberculoma could simulate other lesions like a glioma, and surgical excision needs to be carried out when in doubt or when there is no appreciable improvement in CT appearances with medical treatment.

[A case report of intracerebral tuberculoma during antituberculous therapy]

A case of multiple intracerebral tuberculoma occurred in the course of anti-tuberculous therapy is reported. A 16-year-old high school boy had been treated with isoniagid, streptomycin and paramino-salicylic acid on the tuberculous pleulitis for 3 months previously. He was admitted to our hospital because of progressive headache associated with vomiting. Neurological examination revealed bilateral full papilledema and incomplete bilateral abducens palsy. An immediate CT study with contrast enhancement demonstrated two small ring-like mass with considerable perifocal edema in the left temporal and occipital lobe, respectively. Intracerebral tuberculoma was considered to be most likely, so the patient was given antituberculous therapy with steroid and mannitol. However, despite of medical decompression, he developed intracranial hypertension aggravated, leading to removal of tumor 7 days after admission. Initially left temporal tuberculoma, which had more extensive and prominent perifocal edema, was successfully excised. The specimen was a walnut-sized granuloma with hard capsule including pus inside. Numerous tuberculous bacilli were identified with Ziel-Nielsen staining technique from the pus. Postoperative course was gratifying, and other tumor in the left occipital lobe, which was also diagnosed as tuberculoma, was treated with continuing administration of isoniagid, ethanbutol and rifampicin. However, the former two drugs were forced to be discontinued because of agranulocytosis. Only rifampicin was maintained for 2 months thereafter but no decrease of the size was observed in serial CT studies. Then left occipital tuberculoma was removed. The pathology was tuberculoma with positive bacilli staining. He discharged 1 month later without any neurological deficit but was on antituberculous therapy (rifampisin) as an outpatient for 3 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatic granuloma. Report of a case successfully treated by hepatectomy and antituberculous therapy

A 62 year-old male presented with high fever, weight loss and painful hepatomegaly. The clinical presentation, results of laboratory studies, angiography and laparotomy suggested hepatic abscess or cholangiocarcinoma. He underwent left lobe hepatectomy, and pathological examinations revealed granuloma. Acid-fast bacilli, fungi and parasites were not identified by special stainings. Hepatic tuberculosis was considered most likely because, after operation, an intermediate-strength purified protein derivative (PPD) skin test gave strongly positive results and his subsequent response to antituberculous treatment was excellent. His complex clinical features and the diagnostic difficulties were outlined.

[Intracerebral tuberculoma. Clinical and x-ray computed tomographic characteristics]

Intracranial tuberculomas have become uncommon in industrial nations, while they still have a high incidence in underdeveloped countries. Four cases of intracerebral supratentorial tuberculomas are reported in this paper. Clinical findings suggestive of tuberculosis were present in only one case. The other cases were thought to be gliomas or metastases and the diagnosis was made only after surgery. The CT scan provided a good image of the lesions whose characteristics, however, were diagnostically confusing. When a tuberculoma is suspected, medical therapy alone should be administered initially. Surgery should be resorted to in cases of markedly increased intracranial pressure.

[Chiasmatic tuberculoma. 2 cases]

The authors report two cases of chiasmatic tuberculomas. They emphasize that diagnosis is still difficult despite CT scan if a picture of tuberculous meningitis is lacking. Surgical approach may be justified when diagnosis remains uncertain, especially as tuberculoma is sometimes responsible for recurrent meningitis.

Intracranial tuberculoma: conservative management

Twenty cases of intracranial tuberculoma were treated by us. A clinical-radiographic syndrome was recognized, consisting of an avascular enhancing mass lesion surrounded by marked edema and associated with relatively less severe clinical manifestations than would have been expected from the size and location of the lesion. This allowed successful medical therapy with three antituberculous drugs for an average of 12 months. Steroids, when used, were beneficial in relieving symptoms of cerebral edema without causing spread of tuberculosis. Medically treated patients had a significantly better functional recovery than those from whom the tuberculoma was excised.

Intracranial tuberculomas: a CT study

CT appearances of 25 tuberculomas are described. The image morphology of the immature forms is small discs and rings with massive oedema. The mature forms appear as large rings or lobulated masses. The large rings enclose a mass, a little more dense than brain; the lobulated masses represent coalesced small discs and rings forming a large tuberculoma. These images are consistent and repetitive in tuberculomas. The larger masses form the surgical group and need excision; the smaller masses form the medical group and have had successful medical therapy with serial scans to document healing. The presence of multiple masses is recorded in 55% of the cases.