Intracranial miliary tuberculomas

QJM: An International Journal of Medicine, Jan 2016

Zhao, Y., Bu, H., He, Jun-Ying

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Intracranial miliary tuberculomas

QJM: An International Journal of Medicine Intracranial miliary tuberculomas 0 Photographs and text from: Y. Zhao, Department of Neurology, the Second Hospital of Hebei Medical University , 215 Heping West Road, Shijiazhuang, Hebei Province 050000 , China; H. Bu 1 Department of Neurology, the Second Hospital of Hebei Medical University , 215 Heping West Road, Shijiazhuang, Hebei Province 050000, China; Jun-Ying He , Department of Neurology, the Second Hospital of Hebei Medical University , 215 Heping West Road, Shijiazhuang, Hebei Province 050000 , China - A 27-year-old woman without tuberculosis contact history presented with intermittent fever, cough and chills for 2 months. On admission, she had a temperature of 40 C. Physical examination of the chest, abdomen and nervous system showed no obvious abnormal findings whereas thoracic computed tomography showed miliary nodules diffusely distributed throughout both lungs. Acute miliary pulmonary tuberculosis was confirmed by sputum culture and the presence of TB-DNA performed by polymerase chain reaction. She received standard antituberculous treatment with isoniazid, rifampicin, ethambutol and pyrazinamide. However, she developed progressive headache, nausea and vomiting after 2 months of antituberculous drugs. Examination of the nervous system showed neck stiffness. Contrastenhanced magnetic resonance imaging (MRI) showed ring-like enhancement of multiple nodular lesions in cerebrum, cerebellum, brain stem, sulci and ventricle, suggestive of caseating granuloma (Figure 1a). She was underwent lumber puncture. The pressure was 205 mmH2O. The content of chloride, glucose and protein were 122.0 mmol/l, 2.38 mmol/l and 0.66 g/l, respectively. The cerebrospinal fluid cytology revealed hybrid cytological reaction, dominated by neutrophils and lymphocytes. Mycobacterium tuberculosis in cerebrospinal fluid was found by modified acid-fast staining method (Figure 1b) and TB-DNA in cerebrospinal fluid was verified by Gene Xpert MTB/RIF. Levofloxacin and corticosteroid were added considering of paradoxical response and resistance to antituberculous regimen. We diagnosed the patient as having intracranial miliary tuberculomas with tuberculous meningitis and miliary tuberculosis. After 2-month of medication, MRI showed reduced lesions. Tuberculous meningitis and tuberculoma are the most common forms of the tuberculosis of central nervous system, which are often seen in miliary tuberculosis. Tuberculomas are most often supratentorial in adults. Intracranial miliary tuberculomas involving with cerebrum, cerebellum, brain stem, sulci and ventricle accompanied with tuberculous meningitis and miliary tuberculosis are very rare. Modified acid-fast staining method is convenient and rapid for identifying M. tuberculosis.1 Funding Tracking Project of Medical Application Technology in Hebei Province (No. GL2012026). Conflict of interest: None declared. 1. Chen P , Shi M , Feng GD , Liu JY , Wang BJ , Shi XD , et al. A highly efficient Ziehl-Neelsen stain: identifying de novo intracellular Mycobacterium tuberculosis and improving detection of extracellular M. Tuberculosis in cerebrospinal fluid . J Clin Microbiol 2012 ; 50 : 1166 - 70 .


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Zhao, Y., Bu, H., He, Jun-Ying. Intracranial miliary tuberculomas, QJM: An International Journal of Medicine, 2016, 65-66, DOI: 10.1093/qjmed/hcv156