International Journal of Case Reports and Images - IJCRI - Case Reports, Case Series, Case in Images, Clinical Images

   
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Tuberculosis: When the key is the brain
Joana Cochicho1, Emília Louro2, Armando Carvalho3
1MD, Resident, Internal Medicine Department, Coimbra Hospital and Universitary Centre, Coimbra, Portugal.
2MD, Attending, Internal Medicine Department, Coimbra Hospital and Universitary Centre, Coimbra, Portugal.
3MD, PhD, Chief of Department, Coimbra Hospital and Universitary Centre, Coimbra, Portugal.

doi:10.5348/ijcri-201601-CL-10094

Address correspondence to:
Joana Marques Cochicho
Hospitais da Universidade de Coimbra
Praceta Prof. Mota Pinto
3000-075 Coimbra
Portugal

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How to cite this article
Cochicho J, Louro E, Carvalho A. Tuberculosis: When the key is the brain. Int J Case Rep Images 2016;7(1):72–74.


Case Report

A 69-year-old male, with a history of obesity and bronchiectasis, presented to Internal Medicine consultation to study abdominal adenopathies documented incidentally on abdominal ultrasound three years before. He had already been submitted to endoscopic ultrasound guided biopsy, which was inconclusive. Blood count, serum angiotensin converting enzyme, interferon-gamma release assay (IGRA) and protein electrophoresis were normal. HIV serology was negative, diabetes was excluded and the patient had no history of exposure to tuberculosis. Chest X-ray was normal. By the time of the first appointment the patient was asymptomatic but six months later he started complaining of dizziness and loss of balance. Positron emission tomography showed hypermetabolic adenopathies in multiple body compartments, including the abdomen, and a focal area on the right hemi cerebellum (Figure 1). MRI scan of brain was performed and a lesion involving the right cerebellar hemisphere and vermis with perilesional edema and mass effect was found. The biopsy revealed granulomas with central areas of necrosis (Figure 2A-B). Even though mycobacteria could not be identified in this sample or in the sputum, neither by culture or nucleic acid amplification (NAA), it was decided to start the patient on multiple drug therapy for tuberculosis (isoniazid, rifampicin, pyrazinamide, and ethambutol), with improvement.


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Figure 1: Magnetic resonance imaging scan of brain coronal section showing the cerebellum



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Figure 2: Histology (A) Aggregation of epithelioid cells forming granulomas with confluent areas of necrosis (H&E stain, x40), (B) Multinucleated giant cell (Langhans type) surrounded by lymphoplasmacytic infiltrate (H&E stain, x500).


Discussion

Despite the decreasing prevalence and mortality of tuberculosis, it is still a non-negligible problem across the globe and the second most deadly infectious agent in the world [1]. Extra pulmonary tuberculosis may have an indolent course and clinical manifestations vary considerably depending on the location, even when central nervous system is affected [2]. The gold standard for the diagnosis of Mycobacterium tuberculosis infection is culture identification. However, in extra-pulmonary tuberculosis its sensitivity ranges between 0–80%. Other methods, such as smear microscopy, NAA tests and IGRAs also have high variability [3]. Although IGRA assays have shown good results in the diagnosis of active tuberculosis in Bacillus Calmette-Guérin vaccinated populations, factors associated with negative results (such as age > 50 and male gender) have been identified and should be taken into account [4].


Conclusion

This report illustrates that the diagnosis of tuberculosis remains a challenge, not only because of its silent course but also due to the suboptimal diagnostic tests available. Although there was no identification of Mycobacterium tuberculosis in our patient, the exclusion of a more probable diagnosis and the risk of not treating a tuberculoma, led to the decision to start tuberculosis treatment.

Keywords: Extra pulmonary tuberculosis, Tuberculoma, IGRA assay


Acknowledgements

We would like to thank Dr. Olinda Rebelo (Neuropathology Laboratory, Neurology Department, Coimbra Hospital and Universitary Centre) for providing histologic images.


References
  1. WHO. Global tuberculosis report 2014 (WHO/HTM/TB/2014.08). World Health Organization, Geneva, Switzerland; 2014. [Available at: http://www.who.int/tb/publications/global_report/gtbr14_main_text.pdf]    Back to citation no. 1
  2. Rock RB, Olin M, Baker CA, Molitor TW, Peterson PK. Central nervous system tuberculosis: pathogenesis and clinical aspects. Clin Microbiol Rev 2008 Apr;21(2):243–61.   [CrossRef]   [Pubmed]    Back to citation no. 2
  3. Mehta PK, Raj A, Singh N, Khuller GK. Diagnosis of extrapulmonary tuberculosis by PCR. FEMS Immunol Med Microbiol 2012 Oct;66(1):20–36.   [CrossRef]   [Pubmed]    Back to citation no. 3
  4. Yan L, Xiao H, Han M, Zhang Q. Diagnostic value of T-SPOT.TB interferon-? release assays for active tuberculosis. Exp Ther Med 2016 Jul;10(1):345–51.   [CrossRef]   [Pubmed]    Back to citation no. 4
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Author Contributions
Joana Cochicho – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Emília Louro – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Armando Carvalho – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2016 Joana Cochicho et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



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