Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
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Radiological Follow-up of a Cerebral Tuberculoma with a Paradoxical Response Mimicking a Brain Tumor

  • Kim, Jeong-Kwon (Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital & Medical School) ;
  • Jung, Tae-Young (Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital & Medical School) ;
  • Lee, Kyung-Hwa (Department of Pathology, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital & Medical School) ;
  • Kim, Seul-Kee (Department of Radiology, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital & Medical School)
  • Received : 2014.04.03
  • Accepted : 2014.06.06
  • Published : 2015.04.28
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Abstract

We report a case of a paradoxical response of a tuberculoma in the brain mimicking a brain tumor. A 76-year-old woman presented with a 2 week history of headache, dysarthia, and orthopnea. Brain magnetic resonance images (MRI) revealed two rim-enhancing lesions on the pons and occipital lobe, and chest computed tomography showed randomly distributed miliary nodules. The tentative diagnosis was tuberculosis (TB) of the brain and lung. She complained of right hemiparesis and worsening general weakness after taking the anti-TB medication. On the monthly follow-up images, the enhanced lesions were enlarged with increased perfusion and choline/creatinine ratio, suggesting a high grade glioma. A surgical resection was completed to diagnose the occipital lesion, and the tuberculoma was pathologically confirmed by a positive TB-polymerase chain reaction. The anti-TB medication was continued for 13 months. A follow-up MRI showed decreased size of the brain lesions associated with perilesional edema, and the clinical symptoms had improved. Brain tuberculoma could be aggravated mimicking brain malignancy during administration of anti-TB medication. This paradoxical response can be effectively managed by continuing the anti-TB drugs.

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References

  1. Afghani B, Lieberman JM : Paradoxical enlargement or development of intracranial tuberculomas during therapy : case report and review. Clin Infect Dis 19 : 1092-1099, 1994 https://doi.org/10.1093/clinids/19.6.1092
  2. Alvarez-Salgado JA, Ruiz-Gines JA, Fuentes-Ventura CD, Gonzales-Sejas AG, Belinchon de Diego JM, Gonzalez-Llanos Fernandez de Mesa F, et al. : [Intracranial tuberculoma simulating a malignant tumor : case report and literature review]. Neurocirugia (Astur) 22 : 600-604, 2011
  3. Be NA, Kim KS, Bishai WR, Jain SK : Pathogenesis of central nervous system tuberculosis. Curr Mol Med 9 : 94-99, 2009 https://doi.org/10.2174/156652409787581655
  4. Burman WJ, Jones BE : Treatment of HIV-related tuberculosis in the era of effective antiretroviral therapy. Am J Respir Crit Care Med 164 : 7-12, 2001 https://doi.org/10.1164/ajrccm.164.1.2101133
  5. Chambers ST, Hendrickse WA, Record C, Rudge P, Smith H : Paradoxical expansion of intracranial tuberculomas during chemotherapy. Lancet 2 : 181-184, 1984
  6. Cheng VC, Ho PL, Lee RA, Chan KS, Chan KK, Woo PC, et al. : Clinical spectrum of paradoxical deterioration during antituberculosis therapy in non-HIV-infected patients. Eur J Clin Microbiol Infect Dis 21 : 803-809, 2002 https://doi.org/10.1007/s10096-002-0821-2
  7. Cheng VC, Yam WC, Woo PC, Lau SK, Hung IF, Wong SP, et al. : Risk factors for development of paradoxical response during antituberculosis therapy in HIV-negative patients. Eur J Clin Microbiol Infect Dis 22 : 597-602, 2003 https://doi.org/10.1007/s10096-003-0998-z
  8. Coffey KC, Carroll VG, Steele RW : Ring-enhancing central nervous system lesions. Clin Pediatr (Phila) 51 : 1115-1118, 2010
  9. Das A, Das SK, Mandal A, Halder AK : Cerebral tuberculoma as a manifestation of paradoxical reaction in patients with pulmonary and extrapulmonary tuberculosis. J Neurosci Rural Pract 3 : 350-354, 2012 https://doi.org/10.4103/0976-3147.102622
  10. DeLance AR, Safaee M, Oh MC, Clark AJ, Kaur G, Sun MZ, et al. : Tuberculoma of the central nervous system. J Clin Neurosci 20 : 1333-1341, 2013 https://doi.org/10.1016/j.jocn.2013.01.008
  11. Garcia-Monco JC : Central nervous system tuberculosis. Neurol Clin 17 : 737-759, 1999 https://doi.org/10.1016/S0733-8619(05)70164-X
  12. Gupta RK, Kumar S : Central nervous system tuberculosis. Neuroimaging Clin N Am 21 : 795-814, vii-viii, 2011 https://doi.org/10.1016/j.nic.2011.07.004
  13. Kumar R : Atypical response to chemotherapy in neurotuberculosis. Br J Neurosurg 12 : 344-348, 1998 https://doi.org/10.1080/02688699844862
  14. Kumar V, Abbas AK, Fausto N, Mitchell RN : Robbins Basic Pathology, Eighth Edition, ed 8. Philadelphia, PA : Saunders/Elsevier, 2007, pp516- 522
  15. Malone JL, Paparello S, Rickman LS, Wagner KF, Monahan B, Oldfield EC : Intracranial tuberculoma developing during therapy for tuberculous meningitis. West J Med 152 : 188-190, 1990
  16. Radmanesh F, Nejat F, El Khashab M : Cerebral infarction as the first presentation of tuberculosis in an infant : a case report. J Microbiol Immunol Infect 43 : 249-252, 2010 https://doi.org/10.1016/S1684-1182(10)60039-4
  17. Smith H : Paradoxical responses during the chemotherapy of tuberculosis. J Infect 15 : 1-3, 1987
  18. Trivedi R, Saksena S, Gupta RK : Magnetic resonance imaging in central nervous system tuberculosis. Indian J Radiol Imaging 19 : 256-265, 2009 https://doi.org/10.4103/0971-3026.57205

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