J Neurocrit Care.  2018 Jun;11(1):47-53. 10.18700/jnc.180045.

Miliary Tuberculosis Mimicking Brain Metastasis from Renal Cell Carcinoma

• Ko Y
• Mo EK
• Park YB
• Kang MR
• Bae JS
• Kim Y

• KMID: 2426214
• DOI: http://doi.org/10.18700/jnc.180045

Abstract

BACKGROUND
Miliary tuberculosis (TB) can cause diagnostic confusion for clinicians because its radiological appearance can resemble that of metastatic cancer.
CASE REPORT
Here, we describe the case of a 72-yearold woman with miliary TB mimicking brain metastasis from renal cell carcinoma. The patient visited our clinic because of dysarthria and sluggish speech. A metastatic cancer such as renal cell carcinoma or brain tumor was suspected. However, the patient was diagnosed with miliary TB associated with multiple intracranial tuberculomas and a subsequent paradoxical response to anti-TB therapy.
CONCLUSION
Clinicians should be aware that miliary TB can mimic metastatic cancer even in older people, especially in TB-endemic regions.

Keyword

Tuberculosis, Miliary; Tuberculoma, Intracranial; Brain neoplasms; Neoplasm metastasis

MeSH Terms

Brain Neoplasms
Brain*
Carcinoma, Renal Cell*
Dysarthria
Female
Humans
Neoplasm Metastasis*
Tuberculoma, Intracranial
Tuberculosis, Miliary*

Figure

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  Figure 1. Axial images of contrast-enhanced computed tomography of the brain show numerous small enhancing masses with marked surrounding edema in both cerebral and cerebellar hemispheres and the brain stem.

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  Figure 2. Magnetic resonance imaging of the brain on admission. (A, B) T1- and T2-weighted axial images, and an image with gadolinium enhancement. Multiple ring-enhancing lesions with surrounding edema are seen in both hemispheres. (C) Diffusion-weighted images. Some abnormal restricted lesions are seen in both hemispheres.

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  Figure 3. (A) Chest radiograph at the time of presentation shows diffuse micronodules involving both lung fields. (B) Chest computed tomography scan in the lung window reveals uniform-sized small nodules randomly distributed throughout both lungs.

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  Figure 4. (A) Contrast-enhanced CT scan of the abdomen shows a 3.0×4.5 cm enhancing mass in the right lower kidney. (B) PET/CT of a fused transaxial view shows high fluorodeoxyglucose uptake (SUVmax=19.5) at the same site. CT, computed tomography; PET, positron emission tomography; SUVmax, maximum standardized uptake value.

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  Figure 5. Percutaneous needle biopsy of the right kidney shows well-formed granulomas scattered in the interstitium of the medulla without obvious necrosis (hematoxylin and eosin staining, ×100).

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  Figure 6. MRI of the brain on follow-up. (A) Follow-up brain MRI after one month of anti-tuberculosis therapy reveals no gross intervening change in the numerous small, ring-enhancing nodules. Several new lesions had developed (arrowheads). (B) Follow-up brain MRI at three months after symptom onset shows a significant decrease in the size and number of lesions and a marked amelioration of the surrounding edema. MRI, magnetic resonance imaging.

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