Tuberculomas

Case contributed by A.Prof Frank Gaillard

Presentation

MVA 50kmph Drove into shop window. Incidental finding in the brain. No obvious external injuries.

Patient Data

Age: 35 years
CT

Ill-defined hypodensity within the right cerebellum has surrounding vasogenic edema. There is mass effect on the fourth ventricle with upstream ventricular dilation and periventricular hypodensities. Peripheral enhancement is seen with central hypoattenuation. No other lesions. No acute hemorrhage.

MRI

A cluster of irregular ring-enhancing lesions in the right cerebellar hemisphere demonstrate a thin complete rim of enhancement, with central T2 hypointensity and diffusion restriction. Moderate expansion of the right cerebral hemisphere and compresses the fourth ventricle. The lateral and third ventricles are dilated and there is transependymal edema.

No abnormal leptomeningeal or pachymeningeal enhancement. No ventricular wall enhancement or intraventricular diffusion restriction. No supratentorial ring-enhancing lesions or abnormal diffusion restriction.

Conclusion:

  1. features favor multiple abscesses and low T2 suggests tuberculosis
  2. obstructive hydrocephalus with transependymal edema
CT

CTA chest:

No aortic or great vessel injury. No mediastinal hematoma. The lungs are clear without evidence of contusion (not shown). No osseous injury (not shown). 

Mediastinal and hilar lymphadenopathy.

CT abdomen and pelvis:

Low density celiac, left gastric, hepatic, porta hepatis and retrocaval lymphadenopathy - ? necrotic malignant or infective. No obvious primary malignancy. There is a small cystic lesion within the neck of the pancreas. No associated pancreatic duct dilation and the appearances are not concerning for pancreatic trauma and no obvious malignant features.

Double IVC as normal variant. No traumatic injuries identified.

Conclusion:

Extensive low density upper abdominal low-density lymphadenopathy. These either represent necrotic malignant or infective (eg TB). In the setting of mediastinal and hilar lymphadenopathy and intracranial findings, features are favored to represent TB. 

Pathology

The patient went on to have a biopsy.

Histology:

Sections show multiple fragments of cerebellar tissue which has areas of a prominent granulomatous infiltrate with surrounding lymphocytic reaction. The granulomas are poorly formed with giant cells and areas of prominent necrosis with no neutrophils seen. No evidence of malignancy is present. No organisms seen on PAS or ZN stains.

TB PCR: M tuberculosis complex: DETECTED

Cuture: MGIT Bottle Result: POSITIVE after 17 days

FINAL DIAGNOSIS: tuberculomas

Case Discussion

This is a good example of CNS tuberculomas with low-density lymph nodes in the abdomen consistent with tuberculous lymphadenitis

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Case information

rID: 65411
Published: 12th Feb 2019
Last edited: 14th Feb 2019
Inclusion in quiz mode: Included

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