Cerebral tuberculosis - a diagnostic challenge

Abstract

Abstract Background: Central nervous system (CNS) tuberculosis (TB) accounts for 1% of all cases of TB and is a major cause of mortality and morbidity. Cerebral tuberculomas represent 30% of CNS TB and is a diagnostic challenge. Case presentation: A 42-year-old male patient, known with alcoholic cirrhosis, performs a cerebral computer tomography (CT) after a lipothymic episode accompanied by right hemiparesis, which showed multiple parenchymal ring-lesions (inflammatory-infectious substrate/secondary tumours). Subsequently, the thoracic-abdominal-pelvic-CT-scan reveals micronodular diffuse pulmonary infiltrate and right pleural effusion. Cerebral Magnetic resonance imaging (MRI) describes bilateral infra/supratentorial lesions, raising the suspicion of tuberculomas. HIV serology was negative, cerebrospinal fluid showed no pleocytosis, but high protein level, pleural lymphocytosis in the pleural effusion and positive GeneXpert test in bronchial aspirate. The diagnosis of military TB with cerebral tuberculomas was established. The outcome was favourable under antituberculous treatment initially associated with corticosteroids. At two months the patient had a significant improvement in pulmonary lesions, but while some cerebral lesions decreased in size other lesions increased (paradoxical reaction). At the 14-month end-of-treatment re-evaluation there was an important regression in number and size of the brain lesions. Conclusions: The diagnosis of cerebral tuberculoma remains a challenge for the clinician due to non-specific clinical and radiological findings. The survival rate is over 80% with early diagnosis and correct treatment.