Brainstem tuberculoma mimicking glaucoma

Abstract

To the Editor: We read with interest the recent article by Drs. Del Brutto and Mosquera.1 They report a case of space-occupying, tumor-like brainstem lesion on MRI that responded dramatically to antituberculous drugs. The authors advocate a trial with antituberculous drugs as a diagnostic tool in the evaluation of enhancing brainstem lesions in patients coming from areas where tuberculosis is endemic. We would like to know the CSF findings or the reason for not performing a lumbar puncture in the patient as the CSF findings may influence the decision on a trial of antituberculous drugs or early biopsy of the lesion. In addition, we wish to respond to their recommendation with an illustrative case. A 39-year-old Chinese woman with good past health developed subacute onset of right sixth nerve palsy as the sole presenting feature. There was no evidence of extraneural tuberculous infection on routine investigations. MRI demonstrated a unifocal 10 mm–diameter rim-enhancing lesion at the right ventrolateral pons. A trial of antituberculous therapy was given, which she only took occasionally. She remained static clinically and radiologically at 7 months after onset. CSF showed elevated protein level, hypoglycorrhachia, and lymphocytic pleocytosis. Microbiologic and cytologic studies were repeatedly negative. She was then hospitalized for supervised antituberculous treatment. Tuberculosis is prevalent in Hong Kong and the incidence of intracranial involvement is higher than that in other developed countries. …