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Indian Journal of Medical Sciences, Vol. 58, No. 12, December, 2004, pp. 527-528 Letter To Editor Intramedullary diffuse tubercular lesion resembling glioma Agrawal Amit, Joshi Rajnish, Badole CM, Gangane Nitin, Dwivedi Sankalp Departments of Medicine, Mahatma Gandhi Institute of Medical Sciences,Sevagram Code Number: ms04086 Sir, Of the various forms of spinal tuberculosis, intramedullary spinal tuberculomas (IMT) are least common (2/100,000 of all tuberculosis).[1] We recently encountered a case, which was diagnosed as glioma after imaging was done, leading to neurosurgical intervention, which later turned out to be a tubercular lesion. This case report underscores the importance of keeping a high degree of suspicion for tuberculosis in an endemic area as ours. A 45 years old HIV seronegative gentleman presented with a gradually progressive weakness in both lower limbs since past two months. About a month later, he developed increased frequency of micturition leading to incontinence fifteen days ago. There was no prior history of fever, trauma, cough, sputum production or weight loss. The general physical examination was unremarkable. Neurological examination revealed hypotonia in both lower limbs (power lower limbs 3/5 distal, 4/5 proximal), and bilateral knee and ankle reflexes were sluggish. Bilateral planters were flexors. Both upper limbs were normal, there were no meningeal signs, spinal tenderness or deformity. Rest of systemic examination was normal. Radiographs of cervico-dorsal spine and chest were normal, MRI cervico-dorsal spine revealed hypointense intramedullary lesion onT1, hyperintense on T2 with minimal enhancement on contrast extending from C6-D6 with obliteration of CSF space. Provisional diagnosis of intramedullary glioma was considered and patient was planned for surgery. He underwent laminectomy extending from C6 to D6 vertebrae. Per-operatively the epidural space was normal, and a vertical incision on the dorsal aspect of cord revealed a firm grayish, relatively avascular intramedullary tumor. This was poorly encapsulated and could be removed partially with difficulty. There was no caseation. Operative impression was of an intramedullary glioma. Histopathology however, revealed it to be tuberculous granulation tissue with well formed epitheloid granulomas and Langerhans type of giant cells. Postoperatively patient deteriorated (lower-limb power 1-2/5 now), and also developed sensory deficit below D4 dermatome. Patient was put on anti-tubercular therapy, and on follow up he made moderate recovery in sensory functions with increased tone in the lower limbs associated with flexor spasms. IMT has been described in young immunosupressed[2] as well as immunocompetent individuals.[3] The clinical presentation is of a subacute spinal cord compression. The magnetic resonance imaging appearance is of a hypointense ring enhancement, with or without central hyperintensity (reflecting caseating necrosis) on T2 images and hypo to isointense rings on Tl images.[4] The isolated intramedullary affection, without either pulmonary or meningeal involvement, as in the present case, is an uncommon finding in present case. This suggests that in the present case silent hematogenous dissemination of primary tuberculosis could be responsible for such an isolated lesion. The mainstay of treatment of IMT is anti-tubercular therapy, but surgical intervention is indicated for (a) large lesions with rapid deterioration of the neurological status, (b) non-specific neuroimaging features, (c) paradoxical increase in the size of the lesion following antituberculous therapy.[5] The present case emphasizes the fact that in an endemic area, tuberculosis can have uncommon presentations and imaging findings can be misleading. In this case due to a provisional diagnosis of glioma, surgical decompression of the lesion was attempted. Had preoperative suspicion of diagnosis of tuberculosis been considered, a more conservative approach could have resulted in a better outcome. REFERENCES
Copyright 2004 - Indian Journal of Medical Sciences |
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