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November 1988, Volume 38, Issue 11

Case Reports

INTRACRANIAL TUBERCULOMA: PARADOXICAL DETERIORATION DURING CHEMOTHERAPY

Arshad Javaid  ( Department of Respiratory Medicine, East Birmingham Hospital, Bordesly Green, East Birmingham B9 SST )
Jon G. Ayres  ( Department of Respiratory Medicine, East Birmingham Hospital, Bordesly Green, East Birmingham B9 SST )

Intracranial tuberculomas although be­coming less frequent, continue to constitute a significant percentage (16—20%) of all intrac­ranial space occupying lesions in Asia and Africa1. With the help of Computed Tomography (CT) it is now possible to diagnose intracranial tuber­culomas reasonably confidently2, whereas until recently the diagnosis of this condition coul.d only be presumptive if aspiration or biopsy of tuberculoma was not performed. Intracranial tuberculomas are known to develop and increase in size after chemotherapy for pulmonary tuber­culosis3. We report a patient with two intracranial tuberculomas which became clinically apparent after chemotherapy was started, the neurological symptoms continuing to deteriorate whilst the pulmonary disease responded satisfactorily.

CASE REPORT

A 25 years old Asian lady who entered the United Kingdom 18 years previously, was admit­ted to hospital with a history of dry cough, night sweats, malaise and loss of 7kg in weight over 2 months. She worked in a factory making cardboard boxes and had recently noticed difficul­ty in using her right hand. On examination she had a mobile non-tender left sided supraclavicular lymph node and a small left sided pleural effusion. No neurological abnormality was noted at this time.
The Mantoux test was strongly positive (22mm induration to 1:100,00) and the chest radiograph revealed bilateral pulmonary infiltra­tion and left sided pleural effusion. She was started on standard quadruple chemotherapy of Rifampicin 10mg/kg, Isoniazid 300mg/day, Etha­mbutol 15mg/kg and pyrazinamide 30mg/kg body wt. There was a good clinical response with improvement in cough and appetite but she developed chorioathetoid movements in her right hand three weeks after the chemotherapy was started. A CT scan showed an ill defmed low density mass extending from the pons almost to the quadrigeminal plate on the left with distortion of the fourth ventricle. After contrast there was
irregular ring enhancement of this lesion (Figure 1).

A further enhancing area was identified iii the left parietal region near the vertex and central sulcus (Figure 2).

A diagnosis of intracranial tubercu­lomas was made. The dose of chemotherapy was increased to Rifampicin 2Omg/kgm, isoniazid 1 5mg/kgm, Pyrazinamide 4Omg/kgm and Etham­butol 25mg! kgm body weight.
Her neurological symptoms continued to progress and she developed twitching of her right leg, pyramedial signs on the right side and an upper motor neurone facial nerve palsy which was presumed to be due to paradoxical expansion of the tuberculomas. The treatment was continued and 2 months after increasing the dose of chemo­therapy an improvement was seen in neurological signs. After 6 months she complained only of occasional twitching in her arm. A repeat CT scan at this stage showed a dramatic reduction in the size of the lesions (Figure 3).

DISCUSSION

In this patient two unsuspected tubercu­lomas were confirmed on CT scan, after neuro­logical signs had appeared following the start of chemotherapy for pulmonary tuberculosis. The signs continued to deteriorate for 2 months despite increasing the doses as is usually recom­mended for tuberculosis of the brain4.
Intracranial tuberculoma is rare in UK but is more common in the Indian Subcontinent. The incidence of intracranial tuberculoma has declined since the advent of effective treatment. Tuberculosis was responsible for about 3040% of all intracranial space occupying lesions at the turn of the century5, whereas in 1972 it was esti­mated to be less than 0.5% of all the space occupy­ing lesions of the brain in the developed countries6. However it is still relatively common in Africa and Asia constituting 16-20% of intracranial lesions.
Intracranial tuberculornas arise from the haematogenous spread of tuberculosis from other parts of the body7 although in one series 42% cases showed no sign of extra-cerebral tubercu­losis8. Multiple tuberculomas are present in 15-34% cases9. The initial infection may be meningeal, miiary or pulmonary. They can occur almost anywhere in the CNS and may cause pres­sure problems according to their10
The advent of CT has made the diagnosis of intracranial tuberculomas easier and provides much clearer details as to the anatomical site. it is also helpful in evaluating the effect of medical treatment2.
Controversies exist regarding the treatment of intracranial tuberculoma; chemotherapy alone is the treatment of choice for all cases not com­plicated by obstructive hydrocephalus but surgical intervention is indicated when the patient’s vision or life is threatened by severe intracranial hyper­tension.
Intracranial tuberculomas are known to develop and enlarge during chemotherapy3. Tuber­culous cervical lymph nodes appear and enlarge” during chemotherapy due to the trapping of antigen reactive lymphocytes within the nodes12 Although the exact mechanisms of this parã­doxical response is unclear, it is suggested that treatment in these cases should continue for longer than is customary for uncomplicated tuber­culous infection3

REFERENCES

1. Sinh, G., Pandya, S.K. and Dastur, DX. Patho­genesis of unusual intracranial tuberculomas and tuberculous space- occupying lesions. J. Neuro­surg., 1968; 29: 149.
2  Bhargava, S. and Tandon, P.N. Intracranial tuberculomas; a CT study. Br. 3. Radiol., 1980; 53: 935.
3. Teoh, R., Humphries, MJ. and Sister Mahony, G .0 . Q. J. Med., 1987; 241:449.
4. Ross, JD. and Horre, N.W. Modern drug treat­ment of tuberculosis. The Chest, Heart and Stroke Association, 1983, 51.
5. Cushing, H. Intracranial tumours. Springfield, Illinois, Thomas, 1932.
6. Maurice-Williams, R.S. Tuberculomas of the brain in Britain. Postgrad. Med. J., 1972; 48:678.
7. Obrador, S. Tuberculoma and syphilitic gumma, in neurological surgery. Edited by Youmans, J.R. Philadelphia, Saunders, 1973, p. 1569.
8. Mayer, M.M., Kaufman, D.M. and Muller, M.H. Recent cases of intracranial tuberculoma. Neuro­logy, 1978; 28:256.
9. Dastur, H.M. A Tuberculoima review with personal experience. Part 1. Neurology, 1972; 20:111.
10. DeAngelis, L.M. Intracranial tuberculoma; case report and review of literature. Neurology. 1981; 31: 1133.
11. Campbell, l.A. and Dyson, A.J. Lymph node tuberculosis; a comparison of various methods  oftreatment.Tubercle, 1971;58: 171.
12. Editorial. Immune reactions in tuberculosis. Lancet, 1984; 2:204.

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