Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 58, Num. 5, 2010, pp. 736-738

Neurology India, Vol. 58, No. 5, September-October, 2010, pp. 736-738

Topic of the Issue: Letter to Editor

Intramedullary tuberculoma in a six year old

Devendra K Tyagi, Srikant Balasubramaniam, Harshad R Purandare, Hemant V Savant

Department of Neurosurgery, BYL Nair Charitable Hospital, TN Medical College, Mumbai, India

Correspondence Address:
Srikant Balasubramaniam
Department of Neurosurgery, BYL Nair Charitable Hospital, TN Medical College, Mumbai
India
srikantbala@yahoo.com

Date of Acceptance: 23-Jun-2010

Code Number: ni10200

PMID: 21045498

DOI: 10.4103/0028-3886.72198

Sir,

Of the patients with tuberculosis, 0.5-2% of patients develop tuberculosis of central nervous system (CNS). ^[1] The reported incidence of intramedullary tuberculoma first described by Serra in 1840, is 2 per 100000 cases of tuberculosis and 2 per 1000 cases of CNS tuberculosis. ^[2] The common age is 18- 45 years and is often associated with tuberculous foci elsewhere. ^[3],[4] In this report we describe a six-year child with intramedullary tuberculoma.

A six-year old immmunocompetent girl presented with progressive weakness of both lower limbs and inability to walk of three months duration. There was no history of contact with patients with tuberculosis. Examination revealed spastic weakness (grade 3/5) of the lower limbs with exaggerated reflexes. There was no sensory deficit or bowel and bladder involvement. X-Ray chest was essentially normal. Magnetic resonance imaging (MRI) of spine showed an intramedullary lesion at D9-10 level which was isointense on T1W images [Figure - 1] with homogenous contrast enhancement. [Figure - 2], T2W images showed a hypointense lesion with central hyperintensity and surrounding hyperintense signal changes [Figure - 3].

She underwent D9-10 laminectomy. Midline durotomy showed a swollen cord. Dorsal midline myelotomy identified a mass lesion with central caseation necrosis and there was a good plane of cleavage from surrounding cord. The tumor was totally excised with minimal use of bipolar coagulation and cord manipulation. Watertight dural closure was performed after achieving hemostasis. Postoperatively there was no worsening of motor power. Histopathological evaluation revealed an ill defined epitheloid granuloma with Langhan giant cells suggestive of tuberculoma [Figure - 4]. She was treated with four anti tuberculosis drugs for 3 months followed by two drugs (INH and Rifampicin) for the remaining 18 months. She showed sustained improvement and at three-year follow-up has normal power in both lower limbs (Grade 5/5) and fully ambulatory.

In tuberculosis, CNS involvement is more commonly due to hematogenous spread from a sub clinical or radiologically occult primary, usually in the lungs. ^[2] Patients with intramedullary tuberculoma often have a history of contact with patients with tuberculosis or an extracranial focus of tuberculosis. ^[4] In our patient both of these were absent. Of the six patients with tuberculoma of spinal cord reported by Bucy and Oberhill, ^[5] three had associated tuberculous lesions elsewhere in the CNS. In the series of intramedullary tuberculomas reported by Mac Donnel et al., ^[2] 38% of the patients had no evidence of tuberculous disease elsewhere.

Intramedullary tuberculoma has been described in young immunocompromised as well as immunocompetent individuals. ^[6],[7] The usual age of presentation is 18-45 years. ^[3] The youngest case described in the literature is that of a nine month old infant. ^[7] Though these lesions are seen at any level of cord, the thoracic cord is the most commonly involved segment. ^[8]

Most of the patients with intramedullary tuberculoma have good functional recovery with anti tuberculous treatment, however, some patients may be left with deficits in spite of adequate antituberculous drug therapy. ^[8,9] Safe excision of intramedullary tuberculoma has been advised when: (1) neurological deficits are present; (2) severe compression of cord parenchyma is evident; (3) diagnosis is uncertain; or (4) there is clinical deterioration in spite of adequate anti tuberculous drug therapy. ^[7],[10] In the series reported by Mac Donnel et al., ^[2] 65% of the patients had recovery after surgical resection. We feel that patients showing radiological increase in the swelling of the cord need not be operated, as this phenomenon could be due to paradoxical response to antituberculous drug therapy and should carefully be followed-up. ^[11]

In conclusion tuberculoma should be considered in the differential diagnosis of all intramedullary space occupying lesions irrespective of age or presence of extracranial focus of tuberculosis in countries endemic to tuberculosis. Most of these patients respond well to anti tuberculous drug therapy with good functional recovery, however, timely surgical decompression in selected cases, provide excellent long-term outcome.

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