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Tuberculoma

Case contributed by Ryan Thibodeau
Diagnosis certain

Presentation

Constant hiccups for the past four days. Evaluate for thoracic mass.

Patient Data

Age: 50 years
Gender: Male
ct

There is bulky right axillary lymphadenopathy. The largest right axillary lymph node measuring approximately 5.0 x 2.7 cm.

Histologic findings of right axillary lymph node dissection reveal confluent granulomatous reaction throughout the lymph node, associated with necrosis.  Special stains for acid fast and fungal organisms (AFB, GMS, DPAS, and mucicarmine) demonstrate rare foci with beaded acid-fast rods, consistent with mycobacterial organisms.  No other organism is demonstrated.

A CT head was ordered to evaluate for intracranial bleed or mass.

ct

There is extensive right parieto-occipital and temporal lobe hypodensity with associated sulcal effacement. There is 1.2 cm leftward midline shift. There is dilation of the left lateral ventricle relative to the right. A relatively hyperdense component within the surrounding vasogenic edema measuring 1.8 x 2.2 cm at the right parieto-occipital junction and may represent an underlying mass.

mri

There is conglomerate of T2 heterogenous irregular peripherally enhancing lesions centered at the right parietotemporal junction measuring 5.1 x 4.4 x 3.6 cm in AP x TR x CC maximum dimensions. There is extensive perilesional T2/FLAIR hyperintensities in the right cerebral hemisphere with the midline shift to the left measuring 1.0 cm. There is effacement of the right lateral and third ventricles with dilatation of the left lateral ventricle concerning for entrapment. There is left periventricular T2/FLAIR hyperintensity concerning for transependymal CSF interstitial edema. There is right uncal and left parahippocampal gyral herniation.

Case Discussion

This is a case of a tuberculoma.

Right parietal resection demonstrate confluent necrotizing granulomatous inflammation involving brain parenchyma. Central caseous necrosis surrounded by epithelioid histiocytes, lymphocytes, plasma cells and multinucleated giant cells including Langhans type are readily identified. Special stains of AFB and FITE were performed on representative blocks which revealed rare, interspersed foci of acid-fast rods, consistent with mycobacterial organisms.

The patient was started on RIPE (rifampin, isoniazid, pyrazinamide, and ethambutol) therapy for 4 months, followed by 2 months of rifampin, INH, and vitamin B6.

CO-AUTHORS:
Daniel Gewolb, MD
Joseph Giampa, DO

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