Tuberculoma Research Articles

Clinical and diagnostic features of central nervous system tuberculosis in Indian children - a descriptive study.

Children with tuberculous meningitis (TBM) present with diagnostic challenges as they often have atypical clinical features. To describe the baseline characteristic features of children diagnosed with central nervous system (CNS) TB (TBM and tuberculoma). Retrospective descriptive study. Children less than 12 years presenting with neurological signs and symptoms were assessed for a therapeutic TBM trial eligibility. The results of their clinical, laboratory, neuroimaging, cerebrospinal fluid evaluations were analysed for TBM diagnosis. Of 600 children evaluated, 61(10%) had CNS tuberculosis; TBM 47, tuberculoma 14. 20(33%) had definite TBM. Mean age of children with TBM was 5 ± 3.4 years. Of 47, 13(28%), 21(45%) and 13(28%) had grade I, II, and III disease respectively. Abnormalities suggestive of TBM in MRI and computed tomography brain were observed in 76% (26/34) and 77% (24/31) respectively. Abnormal cerebrospinal fluid white blood cell count, protein and glucose were observed in 56% (24/43), 49% (22/45), 47% (21/45) respectively. Among 41 patients with TBM followed up until discharge, five died. Younger children with TBM have severe forms. Confirmatory results may not be available in all. A holistic approach to care including addressing complications of hydrocephalus and strokes is needed.

Inflammatory activity and markers of extracellular matrix destruction in pulmonary tuberculoma

Aim . To correlate the concentration of markers of extracellular matrix (ECM) destruction in peripheral blood with morphological characteristics of inflammatory activity and to evaluate their applicability in determining treatment strategy for patients with pulmonary tuberculoma (TUB). Materials and methods. Peripheral blood samples were taken from 87 patients diagnosed with TUB. The concentrations of matrix metalloproteinases (MMPs), such as collagenases (MMP-1 and MMP-8), stromelysin (MMP-3), gelatinase (MMP-9), and tissue inhibitors of metalloproteinases (TIMP-1), were measured using the ELISA method (R&D Systems, Minneapolis, MN, USA). The activity of α 2 -macroglobulin (MG), neutrophil elastase (NE) and proteinase inhibitor (PI) were measured using enzyme assays; acute phase reactants (APR) – haptoglobin (GP) and α 1 -acid glycoprotein (AGP) – were measured using immunoturbidimetric assays (Thermo Fisher Scientific, USA). Statistica 7 software package and the predictive classification method (PCM) were employed for data analysis. Results . It has been established that TUB as a clinical form of pulmonary tuberculosis (TB) is characterised by enzyme imbalance between MMP, NE and their inhibitors, namely, by an increase in the levels of MMP-1, MMP-8, MMP-9, and NE and a decrease in MG without changes in MMP-3, TIMP-1 and PI. There is a clear correlation between markers of ECM destruction in blood and morphological characteristics of inflammatory activity. The combinations of MMP-1 and MG can serve as a diagnostic criterion for caseous necrosis in the TUB centre (the alterative component of inflammation), while the levels of MMP-8 and MG can be indicative of granulomatous changes in the capsule (the productive component of inflammation). Various combinations of markers of ECM destruction (with or without APR) enable to predict a particular morphological pattern with accuracy from 80% up to 92%. Conclusion. When determining a treatment strategy for patients with TUB, biochemical data which allow to assess the tempo and intensity of the inflammation process should be taken into account along with a dataset of clinical and radiological features.

"Crown and necklace" appearance of cisternal tuberculoma.

"Crown and necklace" appearance of cisternal tuberculoma.

Clinical treatment of epilepsy caused by AIDS-related encephalopathy

Objective To explore the clinical characteristics, diagnostic method of epilepsy caused by acquired immunodeficiency syndrome(AIDS)-related encephalopathy and the value of surgical treatment. Methods A retrospective analysis was conducted on 12 patients with epilepsy caused by AIDS-related encephalopathy admitted to Department of Neurosurgery, Beijing Ditan Hospital, Capital Medical University from June 2012 to January 2018. Of the 12 patients, 4 had intracranial lymphoma, 4 had intracranial tuberculoma, 2 had cryptococcal meningitis with intracranial hypertension and 2 had Toxoplasma encephalopathy. Three of them had intracranial multiple occupancies. Ten patients underwent pathological excision and 2 of them with hydrocephalus underwent ventriculo-peritoneal shunt simultaneously. Twelve patients received regular drug therapy and highly active antiretroviral therapy treatment before and after operation. Results The symptoms of epilepsy were significantly improved after 6 months to 2 years of follow-up except for 1 case who died of brain edema on the 6th day after operation. Among them, Engel grade Ⅰ was achieved in 7 cases, Engel grade Ⅱ in 3, Engel grade Ⅲ in 1. Conclusions The seizure types and pathogenic factors of AIDS-related epilepsy patients are complex and diverse. Comprehensive treatment should be carried out according to clinical manifestations, laboratory examinations, imaging characteristics, electroencephalogram and medical treatment. Under the condition of full preoperative evaluation and mastery of indications, surgery could effectively control AIDS-related epilepsy. Key words: Acquired immunodeficiency syndrome; Epilepsy; Neurosurgical procedures; Treatment outcome; Clinical features

Comparative Evaluation of Brain Tuberculosis and Metastases Using Combined Analysis of Arterial Spin Labeling Perfusion and Diffusion Tensor Imaging

PurposeTo differentiate intra-axial tuberculomas (TB) from metastases based on quantitative differences in the perfusion and diffusion indices of lesion and perilesional edema using arterial spin labeling (ASL) and diffusion tensor imaging (DTI) techniques. Materials and methodsThis prospective study included newly diagnosed untreated 12 patients of TB and 13 of metastases who underwent routine magnetic resonance imaging including DTI and ASL sequences. A region of interest analysis was performed and cerebral blood flow (CBF) values of lesion (L), perilesional edema (PE), and normal contralateral white matter (CWM) were calculated. To account for individual patient variation CBF values were normalized (n) to CWM to obtain the nCBFL and nCBFPE ratios. Similarly, DTI data was processed to obtain fractional anisotropy (FA), mean diffusivity, radial diffusivity, and axial diffusivity values from the lesion and PE. ResultsMetastatic lesions revealed statistically significant (p = 0.001) high values of median nCBFL than TB whereas the difference in the median nCBFPE was not statistically significant (p = 0.174). TB showed higher median FAL compared to metastases (p = 0.031) while no statistically significant difference was found in mean values of other diffusion parameters such as mean diffusivity, radial diffusivity and axial diffusivity. Analysis by the receiver operating characteristic curve method revealed a cut-off value of ≥2.865 for nCBFL (Sensitivity = 0.85, Specificity = 0.84, positive predictive value (PPV) = 0.85, Negative predictive value (NPV) = 0.83) and ≤0.073 for FAL (Sensitivity = 0.77, Specificity = 0.58, PPV = 0.67, NPV = 0.70) in differentiating metastases from TB. ConclusionCombined analysis of noncontrast ASL perfusion and DTI technique may markedly benefit in differentiation of TB from metastases.

Atypical imaging findings in a case of intracranial tuberculoma

Tuberculosis is a major public health problem in developing nations like India. Tuberculosis of the central nervous system is not uncommon. Meningitis and tuberculoma are the two most important manifestations of tuberculosis of the CNS. Intracranial tuberculomas can present as solitary lesion or multiple lesions. Many atypical radiological findings of tuberculomas are known. They may be indistinguishable from cranial abscess or primary brain tumour. In India, tuberculoma should be considered as a differential in patients with intracranial mass lesions. We present a case of intracranial tuberculoma mimicking a high grade gliomas on magnetic resonance imaging and clinical presentation. A 58-year-old male presented with one-month history of epilepsy. Cranial magnetic resonance imaging showed a in right gangliocapsular region peripheral ring-enhancing lesions with central necrosis and one of the lesion showing thick wall enhancement and highly raised choline/creatinine rat. There was a strong suspicion of glial tumour. On CSF studies of the patient, 100% lymphocytes were noted and no malignant cells were seen. The patient was treated with antituberculous chemotherapy.

The clinical features of intracranial tuberculoma and surgical treatment

Objective To investigate the clinical characteristics of intracranial tuberculoma and its diagnosis and outcomes of surgical treatment. Methods In this retrospective study, clinical data including manifestations, imaging, laboratory tests and surgical outcomes of 8 adults were analyzed who were consecutively identified with intracranial tuberculoma from August 2013 to April 2016 at Department of Neurosurgery, Beijing Ditan Hospital, Capital Medical University. Results Among the 8 patients with intracranial tuberculoma, the human immunodeficiency virus (HIV) infection was identified in 4 cases and tuberculosis (TB) involving other systems was found in 3 cases. Out of the 8 patients, lesions were supratentorial in 5 cases and located in posterior fossa of the remaining 3 cases. Seven cases underwent total resection and stereotactic biopsy was performed in 1 case. Pathological acid-fast stain demonstrated positive results and confirmed the diagnosis of tuberculoma. All the patients were regularly treated with anti-tuberculosis drugs. One case died from HIV-related complications 1 year post operation and the rest recovered well. Conclusions The clinical characteristics of intracranial tuberculoma vary depending on its location. The supratentorial tuberculoma commonly caused epilepsy and headache and the subtentorial lesion often presented with symptoms related to high intracranial pressure due to hydrocephalus. The diagnosis should be based on a combination of clinical manifestations, imaging features, laboratory examination and anti-tuberculosis efficacy. With strict following of its indications, surgical treatment might be effective. Key words: Tuberculoma, intracranial; Disease attributes; Neurosurgical procedures

MRI features of cerebral parenchymal tuberculosis and the dynamic evolution during antituberculous treatment

To investigate the MRI features, classification and the evolution of cerebral parenchymal tuberculosis (TB) during anti-tuberculosis treatment. A total of 134 patients with cerebral parenchymal TB registered in our hospital from Sep. 2010 to Aug. 2010 were studied retrospectively. There were 68 males and 66 females, aged 14 to 77 years. The MRI characteristics of these patients were analyzed after T1WI, T2WI, DWI and enhanced scan.The millet, small and large nodules were named by the lesion diameter of less than 0.3 cm, 0.3 to 1.0 cm and lager than 1.0 cm in brain parenchymal TB, respectively, and accordingly the cerebral parenchymal TB cases were divided into millet nodule type, small nodule type, large nodule type and mixed nodule type with at least 2 of 3 nodule sizes. According to the enhanced scanning patterns and signal characteristics, the cases were divided into hyperplastic nodule, tuberculoma type, abscess type and mixed type. Serial follow-up MRI scans were performed in 76 patients during their anti-tuberculosis treatment.Data on lesions of different size were analyzed by Chi-square test and the follow-up results were analyzed by single-factor logistic regression. Of all the 134 patients, the lesions were commonly found in the cerebral hemisphere and cerebellar hemisphere, often multiple in different locations. Three patterns of homogeneous enhancement, ring enhancement, and variegated enhancement were found in the 134 patients after the enhanced scan, of which 2 or more patterns co-existed in 72 cases. There were 124 cases with millet nodules, of which 116 were homogeneous enhancement and 32 were heterogeneous enhancement (including ring enhancement and variegated enhancement). Ninety cases were found to have small nodules, of which 34 were homogeneous enhancement and 69 were heterogeneous enhancement. Sixty cases were found to have large nodules, of which 1 was of homogeneous enhancement and 16 were of heterogeneous enhancement. The case number of the homogeneous enhancement and heterogeneous enhancement was significantly different for the 3 different sized nodules, respectively (P<0.05). Homogeneous enhancement was seen commonly in millet nodules, while heterogeneous enhancement in small nodules especially large nodules. In contrast to small nodule type (8 cases) and large nodule type (1 case), millet nodule type (68 cases) and mixed nodule type (57 cases) were predominant. The hyperplastic nodule type (64 cases) and mixed cerebral tuberculosis (60 cases) were predominant in contrast to tuberculoma type (9 cases) and abscess type (1 case) in the 134 patients. The cases with lesion diameter more than 0.5 cm mostly showed tuberculoma. The disappearance rates were 23 (30.3%) among 76 patients with serial MRI follow-up scans. The disappearance rate of hyperplastic nodule type (17/37) was significantly higher than that of the non-hyperplastic nodule type (including tuberculoma and mixed type) (6/39) (P=0.004). The disappearance rate of millet nodule type (15/38) was significantly higher than that of the non-millet nodule type (8/38) (P=0.02). Single-factor logistic regression analysis showed that, the results of the follow-up only related to 2 classifications (P<0.05). Fourteen patients were found to have enlarged lesions or newly appeared lesion during anti-tuberculosis treatment, of which 3 were refractory. Cerebral parenchymal TB showed certain MRI characteristics. Homogeneous enhancement, ring enhancement, and variegated enhancement. About half of the patients had more than 2 enhancement patterns. Homogeneous enhancement and heterogeneous enhancement were commonly seen in millet nodules and small nodules especially large nodules, respectively. According to the classification of lesion size, millet nodule type and mixed nodule type were predominant. According to the characteristics of the lesion enhancement pattern and signal characteristics, hyperplastic nodule type and mixed type were predominant. This classification would help to guide the treatment of cerebral parenchymal TB. The treatment effect of hyperplastic nodule type was better than non-hyperplastic nodule type, and millet nodule type was better than non-millet nodule types.

The advantage of delayed-phase multi-slice Computed Tomography for the diagnosis of intracranial tuberculosis

To study the advantages of delayed phase scan at 5 minutes using multi-slice Computed Tomography (CT) for the diagnosis of intracranial tuberculosis. Conventional non-contrast and dual-phase contrast enhancement were performed using 16-slice spiral CT for brain scanning. Arterial phase was performed 25 seconds after the injection of contrast agent, and the delayed phase was performed at 5 minutes. Then the ability of two phase images in intracranial tuberculosis displaying was evaluated. A total of 526 lesions in 30 patients were found. Delayed phase scan was superior to arterial phase in the ability of displaying the thickening of meninges, either basal cistern, pia mater or ependymal (P<0.01). The demonstration of lesion size and margins of tuberculoma was also better in delayed phase scan (P<0.01). The delayed phase scan was significantly better in distinguishing lesions and adjacent vascular sections in the sulcus (P<0.01). The delayed phase scan has obvious advantages in the display of intracranial tuberculosis.

Misdiagnosed Intracranial Tuberculoma

Merkezi sinir sistemi MSS tuberkulozu nadir gorulmesine ragmen tedavi gecikirse norolojik sekellere ve mortaliteye yol acmaktadir. Dokuz yasinda kiz hasta konvulziyon gecirme yakinmasiyla klinigimize getirildi. Konvulziyonlari devam ettigi icin cekilen kranyal manyetik rezonans goruntuleme MRG goruntulemelerine gore akut disemine ensefalomyelit dusunulerek steroid tedavisi verilmis. Konvulziyonlarinin tekrarlamasi nedeniyle tarafimiza getirilen hastanin muayenesinde bilateral papilodem disinda patolojik muayene bulgusu saptanmadi. Tuberkulin deri testi 19 mm bulundu. Tuberkulin deri testi pozitifligi, tuberkulozlu bireyle temas oykusu, toraks ve kranyal goruntulemelerde tuberkulozla uyumlu bulgular, hastanin semptom ve muayene bulgulari ile birlikte degerlendirilerek intrakraniyal tuberkulom tanisi kondu. Antituberkuloz tedavi ve deksametazon tedavisi baslandi. Hastanin iki yillik izleminde herhangi bir komplikasyon gozlenmedi. Intrakraniyal tuberkulom MSS tuberkulozunun nadir rastlanan, morbidite ve mortalitesi yuksek bir formudur. Klinik, laboratuvar ve goruntuleme yontemlerinin spesifik olmamasi nedeniyle, MMS patolojilerinde ayirici tanida akilda tutulmasi gerekir. Erken tani ve tedavi iyi prognoz acisindan onemlidir

One case of external fertilization pregnancy combined with hematogenous pulmonary tuberculosis and intracranial multiple tuberculoma

One case of external fertilization pregnancy combined with hematogenous pulmonary tuberculosis and intracranial multiple tuberculoma

Role of Immunological Markers in the Diagnosis, Treatment and Follow-Up of Human Neurocysticercosis

Neurocysticercosis is the commonest parasitic disease of the nervous system. Its clinical manifestations are highly variable ranging from asymptomatic disease to recurrent seizures and multisystem involvement. The imaging findings of neurocysticercosis although typical are not diagnostic for the disease and can be confused lesions of tuberculomas. To circumvent the diagnostic difficulty various serological tests have been tried. Most of the early serological tests were limited by low sensitivity and specificity for the diagnosis. Recently better antibody based assays like Enzyme Linked Immuno Electro Transfer Blot (EITB) have vastly improved the specificity of diagnosis, but sensitivity esp. in single cystic lesions still remains suboptimal. Further advances in the field of serodiagnosis of neurocysticercosis, especially focusing on validation of emerging techniques of diagnosis, will be required before the can be implemented for routine use.

Study of MRI features of intracranial tuberculosis and its dynamic evolution during antituberculous treatment

Objective To explore MRI features of intracranial tuberculosis,and the dynamic evolution of intracranial tuberculosis during antituberculous treatment.Methods From September 2009 to February 2012,seventy-two patients with intracranial tuberculosis were reviewed retrospectively.Intracranial tuberculosis lesions were divided into 3 categories:pure parenchymal tuberculosis,tuberculous meningitis and hybrid type with both parenchymal tuberculosis and tuberculous meningitis.The MRI characteristics of these lesions were analysed.According to the lesion size,pure parenchymal tuberculosis was divided into 3 subtypes:0.3 cm or less was defined as miliary,＞ 0.3 cm and ＜ 1.0 cm as nodule,greater than or equal to 1.0 cm as tuberculoma.Serial follow-up scans were performed in 36 patients,and dynamic MRI changes in the process of anti-tuberculosis treatment during 3 to 6 months were observed.The disappearance rate of the lesions was calculated and statistically analysed by using Chi-square test.Results There were 883 lesions in 38 cases with parenchymal tuberculosis.Multiple lesions distributed widely,423 lesions (47.9％) ≤0.3 cm,330 lesions (37.4％) between 0.3-1.0 cm,and 130 lesions (14.7％) ≥ 1.0 cm.Twenty-four cases with tuberculous meningitis showed meningeal enhancement at basilar cistern.Ten cases with hybrid type presented both parenchymal tuberculosis and meningitis.Among 36 patients with serial MRI follow-up scans,22 cases were pure parenchymal tuberculosis.The disappearance rates of military,nodules and tuberculomas were 52.2％ (59/113),33.3％ (33/99) and 0,respectively,after 3 months treatment.The disappearance rates were 87.6％ (99/113),50.5％ (50/99) and 18.2％ (2/11),respectively,after 6 months treatment.Disappearance rate of miliary lesions was obviously higher than that of nodules at both 3 and 6 months,and the difference was statistically significant,(x2 =7.657,34.786,P ＜ 0.01).Nine lesions of parenchymal tuberculosis enlarged with paradoxical response to antituberculous chemotherapy at 3 months,and 8 of them disappeared after 6 months of therapy.The outcome of tuberculous meningitis was relatively poor.Conclusions It is objective to classify parenchymal tuberculosis into three types:miliary,nodules and tuberculoma.Dynamic MRI changes of intracranial tuberculosis is helpful for understanding the disease better. Key words: Tuberculosis, central nervous system; Magnetic resonance imaging

A case of ano-rectal tuberculoma simulating cancer in AIDS

A case of ano-rectal tuberculoma simulating cancer in AIDS

Diagnosis and treatment of tuberculosis of the central nervous system in children

Abstract Central nervous system infections in children result from the hematogenous dissemination of Mycobacterium tuberculosis from primary pulmonary infection and the formation of small subpial and subependymal foci in the brain and spinal cord, causing meningitis or tuberculoma. The general principles of diagnostic and therapeutic approach to these tubercular infections are discussed in this article.

Paradoxical Worsening of Brain Tuberculomas During Treatment

Marco A. Lima. Fundacao Oswaldo Cruz. Instituto Nacional de Infectologia Evandro Chagas. Documento produzido em parceria ou por autor vinculado a Fiocruz, mas nao consta a informacao no documento.

&amp;ldquo;Paradoxical Tuberculomas after Completion of Antituberculous Treatment&amp;rdquo; by Ira Shah (Vol. 40 No. 1, 15&amp;ndash;17, 2012)

[This corrects the article on p. 15-17 in vol. 40.].

Diagnosis, treatment and misdiagnosis analysis of intracranial tuberculoma

Objective To explore the diagnosis, treatment and misdiagnosed reasons of intracranial tuberculoma. Method The clinical data of 24 cases with intracranial tuberculoma treated in our department from January 1997 to May 2010 were analyzed retrospectively. Results In all 24 cases, 13 cases underwent surgical treatment,2 cases underwent stereotactic biopsy and were confirmed by pathological examinations. 9 cases were regularly treated with anti - tuberculosis drugs. 1 1 cases of intracranial tuberculoma did not be diagnosed echinococcosis before operation, with the misdiagnosis rate of 46％. Conclusions Intracranial tuberculoma is usually diagnosed based on clinical history with auxiliary inspections. With drug consolidate treatment after operation, the prognosis is good. Non - characteristic clinical features, non - characteristic radiographic manifestations contribute to misdiagnosis. Key words: Tuberculoma,intracranial; Diagnosis ; Therapy; Diagnostic errors

Role of EEG and CT scan in partial seizures in children

Seizures disorders are the most prevalent serious neurological disease. Partial seizures are the most common form of seizures in children. This study was carried to determine the etiology and intracranial lesions in children with partial seizures with prospective study through the period of 5 years. One hundred and seventy two children with partial seizures (>2 attacks) were included in the study. All children had contrast CT scan of head and EEG. About 70% of children had their first episode of seizure before 6 years of age. The most common type of seizures was complex partial and the most common lesion on CT scan head was ring enhancing lesion (56.07%). For diagnosis of partial seizures detail history and CT scan head are essential. Key words: Partial seizures, neurocyticercosis, tuberculoma, CT scan.

Tuberculosis of the central nervous system experienced at the International Medical Center of Japan

In spite of recent advances in diagnosis and chemotherapy of tuberculosis, prognosis of tuberculosis of the central nervous system (CNS) is still poor. We evaluated clinical characteristics of 14 patients with the CNS tuberculosis (10 male and 4 female, 21 to 71 years of age) who were hospitalized at IMCJ from 1988 to 1997. Twelve patients had tuberculous meningitis (2 of them had also intracranial tuberculoma), 1 had intracranial tuberculoma and 1 had spinal cord tuberculosis. For the acid-fast bacilli, the smears of cerebrospinal fluids (CSF) were all negative but the cultures for M. tuberculosis were positive in 5. Using PCR method, M. tuberculosis was identified from CSF specimens in 2 out of 9 culture negative patients, thus suggesting the usefulness of the PCR for the rapid diagnosis of CNS tuberculosis. The adenosine deaminase (ADA) levels in CSF may provide another diagnostic clue because they were elevated in 8 out of 10 cases. It is to be noted that there were three patients who developed clinical manifestations of CNS tuberculosis after the initiation of chemotherapy for pulmonary tuberculosis. In the last five cases, four-drug regimen which included PZA, was used with a good result. The success could be related to the addition of PZA which penetrates blood-brain barrier just as good as INH. Two patients died and one remains unconscious with severe neurological sequelae. The present study indicates that positive CSF culture, hydrocephalus and consciousness disturbance are important factors in determining poor prognosis of the CNS tuberculosis.