Q J Med 2014; 107:391–392

doi:10.1093/qjmed/hct158 Advance Access Publication 30 July 2013

Clinical picture

Intracranial tuberculoma

A 20-year-old previously healthy woman without

tuberculosis contact history presented with intermit-
tent fever, mild cough, headache and general mal-
aise for 1 month. On admission, both physical and
neurological examinations, as well as laboratory
tests of the well-nourished patient were grossly
negative, whereas chest plain film (Figure 1a) dis-
closed miliary mottling. With the diagnosis of mil-
iary tuberculosis, she was prescribed four-combined
antituberculous regimen with rifampicin, isoniazid,
ethambutol and pyrazinamide. The sputum cultures
subsequently grew Mycobacterium tuberculosis.
However, intermittent fever accompanying wor-
sening protracted headache and nausea developed

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2 weeks after the start of regular antituberculous ther-
apy. Contrast-enhanced brain computed tomography
scan (Figure 1b) revealed multiple ring-enhanced
lesions with peri-focal edema (arrows) in the cerebel-
lum and cerebrum. Under the impression of intracra-
nial tuberculomas with paradoxical response to
antituberculous therapy, corticosteroid was added
for resolving brain edema. After completing the
12-month antituberculous treatment, her symptoms
abated and chest plain film turned to normal.
Central nervous system tuberculosis, usually de-
veloping due to hematogenous dissemination of
bacilli from an infection foci elsewhere in the body,
accounts for about 20% of all cases with extrapul-
monary tubercuolosis.1 While intracranial tuberculo-
mas are responsible for 5–30% of all intracranial
space-occupying lesions in developing countries.2
With common manifestations including headache,
generalized convulsions and hemiparesis, the diagno-
sis of intracranial tuberculoma is usually established
by radiologic imaging, pathologic examinations and
clinical response to antituberculous therapy.3
Patients with intracranial tuberculosis should re-
ceive a prolong course of antituberculous therapy Figure 1. (a) The chest plain film of a 20-year-old woman
disclosing miliary mottling over bilateral lung fields.
for 12–30 months.4 During the therapy, witness of
(b) Contrast-enhanced brain computed tomography scan
new intracranial tuberculoma or expansion of exist-
of the woman revealing multiple ring-enhanced lesions
ing lesions has been documented worldwide and with peri-focal edema (arrows) in the cerebellum and
thought as an immune-mediated paradoxical re- cerebrum.
sponse to the antituberculous therapy.5 For such

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392 Clinical picture
patients, further management should be adding sys-
temic steroid as adjuvant therapy for 4–8 weeks,
rather than changing antituberculous regimen.5
Prompt recognition and appropriate therapy would
prevent unwanted outcomes.
Photographs and text from: F.-F. Tsai, Division of
Chest Medicine, Department of Internal Medicine,
Saint Mary’s Hospital Luodong, Yilan, Taiwan; C.-C.
Shiao, Division of Nephrology, Department of
Internal Medicine, Saint Mary’s Hospital Luodong,
and Saint Mary’s Medicine, Nursing and
Management College, Yilan, Taiwan; S.-Y. Lin,
Division of Infection control, Department of
Internal Medicine, Saint Mary’s Hospital Luodong,
Yilan, Taiwan; H.-M. Tai, Division of Chest
Medicine, Department of Internal Medicine, Saint
Mary’s Hospital Luodong, Yilan, Taiwan, ROC.
email: chungyy2001@yahoo.com.tw
Conflict of interest: None declared.
References
1. Kumar R. Atypical response to chemotherapy in neurotuber-
culosis. Br J Neurosurg 1998; 12:344–8.
2. Alkhani A, Al-Otaibi F, Cupler EJ, Lach B.
Miliarytuberculomas of the brain: case report. Clin Neurol
Neurosurg 2006; 108:411–4.
3. Idris MN, Sokrab TE, Arbab MA, Ahmed AE, El Rasoul H,
Ali S, et al. Tuberculoma of the brain: a series of 16 cases
treated with anti-tuberculosis drugs. Int J Tuberc Lung Dis
2007; 11:91–5.
4. Lee WY, Pang KY, Wong CK. Brain tuberculoma in Hong
Kong. Hong Kong Med J 2002; 8:52–6.
5. Hejazi N, Hassler W. Multiple intracranial tubervulomas
with atypical response to tuberculostatic chemotherapy: lit-
erature review and a case report. Acta Neurochir (Wien)
1997; 139:194–202.
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