Teaching NeuroImages: Central nervous system tuberculomas
Muhammad U. Farooq, MD and
Emily Yonker, MMS, PA-C
From the Department of Neurology and Ophthalmology (M.U.F.), Michigan State University, East Lansing; and Department of Neurosurgery (E.Y.), Bronson Methodist Hospital, Kalamazoo, MI.
Address correspondence and reprint requests to Dr. Muhammad U. Farooq, A-217 Clinical Center, Department of Neurology and Ophthalmology, Michigan State University, East Lansing, MI 48823 Muhammad.farooq{at}ht.msu.edu
A 10-year-old girl presented with 3 weeks of headache, fever,anorexia, and horizontal diplopia after recent travel to India.She was found to have right abducens nerve palsy.
Brain MRI showed multiple ring enhancing lesions (figure 1).The differential included neurocysticercosis, toxoplasmosis,histoplasmosis, blastomycosis, tuberculosis, and metastaticbrain lesions.1 The presence of cranial nerve findings, diffusemeningeal and especially basilar enhancement, and both supratentorialand infratentorial lesions favored tuberculosis. The involvementof the interpeduncular fossa, choroid plexus, and optic chiasm;arterial narrowing at the base of the brain; and target signs(central calcifications of the lesions on CT) were other findingssuggestive of tuberculosis. Her chest X-ray was unremarkable.The CSF analysis showed elevated protein (130 mg/dL), low glucose(19 mg/dL, with serum glucose 76 mg/dL), and 110 mononuclearcells/mm3. Brain biopsy (figure 2) confirmed the diagnosis oftuberculosis. She had marked improvement on rifampicin, isoniazid,pyrazinamide, ethambutol, and dexamethasone.
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