J Korean Neurosurg Soc.  2015 Apr;57(4):307-310. 10.3340/jkns.2015.57.4.307.

Radiological Follow-up of a Cerebral Tuberculoma with a Paradoxical Response Mimicking a Brain Tumor

• Kim JK
• Jung TY
• Lee KH
• Kim SK

• KMID: 1956433
• DOI: http://doi.org/10.3340/jkns.2015.57.4.307

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.

Keyword

Brain; Paradoxical; Tuberculoma; Tumor

MeSH Terms

Aged
Brain
Brain Neoplasms*
Diagnosis
Edema
Female
Follow-Up Studies*
Glioma
Headache
Humans
Lung
Magnetic Resonance Imaging
Occipital Lobe
Paresis
Perfusion
Pons
Thorax
Tuberculoma*
Tuberculosis

Figure

• 

  Fig. 1 Radiological findings. The lesions were hypointense on T1-weighted images, and iso-intense with a central hyper-signal on T2-weighted images associated with perilesional edema and rim-enhancement after contrast administration (A, B, and C). The diffusion images showed diffusion restriction in the central area but no increased cerebral blood volume on MR perfusion images (D and E). At the one month follow-up, the thickened peripheral enhanced lesion was enlarged and associated with aggravated perilesional edema (F, G, and H). The lesion showed increased perfusion and restricted diffusion (I and J). Magnetic resonance spectroscopy revealed an increased choline/creatine ratio of 6.35 and a lactate and lipid peak (K). The lesion decreased in size with less perilesional edema (L, M, and N), and perfusion decreased after 13 months (O).

• 

  Fig. 2 Pathologic findings. The biopsy showed chronic granulomatous inflammation with focal necrosis (hematoxylin and eosin staining, original magnification, ×100).

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