Case Report

TUBERCULOMA

By :
dr.Mustikayani
Supervisor:
dr.Abdul Muis, Sp.S (K)

NEUROLOGIST EDUCATION PROGRAM

MEDICAL FACULTY HASANUDDIN UNIVERSITY
MAKASSAR
2019
 REGISTRATION
• Name : Mrs. M
• Age / Date of Birth: 40-years-old / 4th Oct 1979
• Occupation : House wife
• Marital Status : Married
• Religion : Moeslem
• Address : West Danga, West Sulawesi
• Body weight : 50 kg
• Registration number : 858737
• Date of Admission : 10 October 2018
• Clock of Admission : 02:33 AM
Chief complain : Headache

History of disease :Since one years

before admission. Felt like being
pressed in all head region,
continuous every time. The pain is
worsen by acytivities and alleviated
with rest. The worst NPRS is 5-6,
current NPRS is 3-4. Vertigo since 1
month ago, exacerbated by change
position, relieved by lying on bed
and closing eyes, accompanied by
nausea and vomiting with the
frequency of one time. Tinnitus was
also present. No fever at this time.
History of fever is positive, nausea and gag
negative. History of hypertension, diabetes,
head trauma and seizure are negative.

History of long cough and family history

with long coughing are absent. There is a
history of decreased body weight since 1
years ago.
 PHYSICAL EXAMINATION
• BP 100/70 mmhg
• HR 80 times/minute regularly
Vital Sign •
•
RR 20 times/minute
37˚C

• GCS E4M6V5

Neurological •
•
Meningeal sign negative
Cortical Function within normal limit
Status • Cranialis nerve : Round pupil, KS
negative/negative. DLR/ILR +/+
recative
Sensoric •Within normal
funtion limit

Autonom •Within normal

function limit
Laboratory Examination
 ELECTROCARDIOGRAPHY

Interpretation :
Sinus tachicardia, HR 124 times/menit, normoaxis
 CHEST X-RAY

Conclusion : Pneumonia suspek Spesific

CT SCAN HEAD WITH CONTRAST
CT SCAN HEAD WITH CONTRAST
• Multiple hypodens lesion, enchanced by
contrast at the edge. The lesion are well-
defined, round, relatively regular with the
size of +/- 2,1 x 2,8 x 2,4 and perifocal
edema around itu, located in
temporooccipital lobe and right cerebellum.
The lessions compress the right lateral
ventricle.
• Gyri : Normal.
• Sulci and Fissure sylvii : Normal
• No midline shift appears
• Ventricular system and subarachnoid space
: Normal
• CPA and pons : Normal
• Paranasalis sinus and aircell mastoid :
Normal
• Bulbus oculi and retrobulbar space : Normal
• Intact bone bones.
Conclusion:
- Multiple hypodense lesion in the lobe
temporooccipital and cerebellum dextra
sugestif abcess.
 WORKING DIAGNOSIS
Clinical • Chronic headache, vertigo, right
Diagnosis hemiparesis

Topical • Hemisphere cerebri

Diagnosis
Etiology • Suspect Brain Tuberculomas
Diagnosis
Differential
• Suspect Abcess Cerebri
diagnosis
THERAPY

• Intravenous Fluid Drips Ringer Laktat 20 drops/minute

• Dexamethasone 10 mg continue 5 mg/6 hours/intravenous (tapp
off every two days)
• Neuroprotektor : Citicoline 500 mg/12 hour/intravenously
• H2 Reseptor : Ranitidine 50 mg/12 hour/intravenously
• Analgetic : Ketorolac 30 mg/12 hour/ intravenously
• Flunarizin 5 mg/12 hour/oral
• Betahistin 6 mg/8 hour/oral

PLANNING
• Suggest to consult pulmonologist
FOLLOW UP
 FINAL DIAGNOSIS
• Chronic headache, vertigo, right
Clinical
Diagnosis
hemiparesis

• Hemisfer cerebri
Topical
Diagnosis • Cerebelli

Etiology
• Brain Tuberculomas
Diagnosis
 DISCUSSION
Tuberculosis (TB)
The nervous system  Few cases of TB brain
 Mycobacterium Brain tuberculosis abscess  Misdiagnosed
tuberculosis

Leading cause of death

Current migratory
Tuberculosis among the infectious
patterns
diseases

WHO declared In 2012 prolonged

tuberculosis = 8587 cases of
nonspecific symptoms
tuberculosis in 2010, 0.6
global emergency per 100000 population
and multiple brain TB
in 1993 demonstrated

Indonesia is TB The incidence rate is

Women (15-44 years ) >
highest among young
endemic regions adult
men to develop active TB

Most common infectious

cause of CNS space We report the case of
TB occupying lesion in female with brain
people with or without tuberculoma.
HIV
Pathophysiology of CNS Tuberculoma
Formation and TBM
Clinical Manifestation
1 • Pleomorphic
2 • >> Intracranial pressure
3 • Fever
4 • Headache
5 • Vomiting
6 • Seizure
7 • Vertigo
8 • Visual impairment
9 • Positive tuberculin test
10 • Positive response to anti-tuberculosis treatment
The diagnosis  Others symptomps
difficult on this patient

Headache since one year

No evidence of
systemic TB from
2/3 patients two- Fever
third of patients
History of fever positif, the fever is
not too high, especially at night

Chest radiographs Vertigo

This patient
have pneumonia
suspect specific
The diagnosis  laboratory and
imaging result
• Xpert MTB/RIF  detect MTB and rifampicin
resistance within 90 minutes. There is certainly
a need for a diagnostic tool with increased
sensitivity and specificity for CNS tuberculoma.
• The gold standard for diagnosis tuberculoma
 biopsy of the suspected CNS lesion with
histopathological analysis.
 Biopsy of
Imaging CT Scan MRI
the brain

• single or • Sensitivity • Detail in • Most

multiple 100 %, isualizing accurate
lesions 1 mm specificity anatomic method of
to 8 cm 85,7% location, edema, diagnosis in
• Further and soft tissue case of
analysis  involvement multiple
MRI • ‘‘target sign”  brain
• Hypodense indicate tuberculomas
with ring tuberculoma,
enhancement while its post-
on CT scans contrast presence
is less specific
DIFFERENTIAL DIAGNOSIS

Abcess Cerebri Cerebral Toxoplasmosis

The Treatment Tuberculoma

WHO  TB treatment Category 1

• Iinitial phase therapy (for 2 months) with isoniazid, rifamfisin and pyrazinamid,
streptomycin or etambutol
• Followed by 7 months continuation phase with isoniazid and rifamficin

Dexamethasone is recommended for 4–8 weeks is a part of adjuvant

therapy

This patient
• Fixed drugs combination anti-tuberculosis drug 4 tablet for two months based on
body weight (50 kg)  7 months with isoniazid and rifamficin
• Dexamethasone tapered gradually every three days  dosage may reduced by 50%
second and third week and then be tapered gradually over next 4 weeks

Clinical improvement being observed

Table 1. The recommended
strengths of fixed dose Table 2. Dosage schedule for
combination formulations of FDCs of WHO- recommended
essential anti-tuberculosis drugs strengths for adults
The surgical
Complications
intervention

Acute complications such as

hydrocephalus or for patients Hyponatremia due to central
with neurological deficits, nervous system infection can be
surgical intervention is caused by adrenal insufficiency
recommended

Aingle lesion with middline

Syndrome of inappropriate
shifts, increases intracranial
secretion of antidiuretic hormone
pressure, fail to respond
(SIADH)
chemotherapy

Cerebral salt wasting syndrome

(CSWS).
Syndrome of inappropriate antidiuretic
hormone secretion (SIADH)
Release of antidiuretic hormone (ADH) and aldosterone.

Increased intracranial pressure and positive pressure on breathing also

trigger the release of ADH.

Dilution of hyponatremia by expansion of extracellular fluid volume

The clinical symptoms of SIADH  lethargy, fatigue, anorexia, thirst,

vomiting, muscle cramps, and loss of muscle stretch reflexes. In more
severe conditions it can be found clinically hypothermia, seizures,
chyene-stokes breathing, stupor, coma, and the worst deaths.
Treatment in SIADH
Rehydration with normal saline is the main
treatment for CSWS.
Fluid that is restored ranges from 800-
1000 ml / 24 hours,
Vasopressin (not yet available in
Indonesia),

Diuretic group Loop diuretic (furosemide),

Goup of osmotic agents (urea, mannitol).

• Management of CSWS with fluid correction and
hyponatremia with intravenous hypertonic
saline, is given for 24 hours slow droplets.
During hypertonic saline administration that is
too fast can cause central pontin myelinosis
(CPM) and salt (NaCl) can be considered after
the patient's condition is stable