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CASE REPORT
Year : 2017  |  Volume : 12  |  Issue : 1  |  Page : 58-61

Third ventricular tuberculoma mimicking as a tumor: Report of a very rare case


Department of Neurosurgery, Om Hospital, Chabahil, Kathmandu, Nepal

Date of Web Publication17-Mar-2017

Correspondence Address:
Gopal R Sharma
Department of Neurosurgery, Om Hospital, Chabahil, Kathmandu
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1793-5482.145061

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  Abstract 

Intracranial tuberculoma is a common neurosurgical problem in developing countries; however, intraventricular tuberculoma is a rare entity. Here, we report a rare case of third ventricular tuberculoma in a 21-year-old girl who presented with features of raised intracranial pressure. Radiological findings and management of third ventricular tuberculoma would be discussed and literature regarding such lesions will be reviewed.

Keywords: Intracranial tuberculomas, third ventricular tuberculoma, transcallosal transventricular excision


How to cite this article:
Sharma GR, Kaushal P, Vaidya B, Kumar P. Third ventricular tuberculoma mimicking as a tumor: Report of a very rare case. Asian J Neurosurg 2017;12:58-61

How to cite this URL:
Sharma GR, Kaushal P, Vaidya B, Kumar P. Third ventricular tuberculoma mimicking as a tumor: Report of a very rare case. Asian J Neurosurg [serial online] 2017 [cited 2017 Sep 21];12:58-61. Available from: http://www.asianjns.org/text.asp?2017/12/1/58/145061


  Introduction Top


Tuberculomas of the central nervous system (CNS) occur at about 0.5-4%, whereas in underdeveloped countries this occurrence is about 15-30%.[1] Intracranial tuberculomas are more common in underdeveloped countries where tuberculosis is endemic.[2] It mainly affects children and young adults.[3]

Conditions that have been associated with the development of and an increase in CNS tuberculosis and tuberculoma include diabetes mellitus, pregnancy, AIDS, intravenous drug use, immunosuppression from advanced age, alcoholism, transplantation and chemotherapy.[3] Intracranial tuberculomas mostly occur in cerebral hemispheres,[4] but may be located anywhere inside the brain. Intraventricular tuberculomas are rare lesions and, among the intraventricular tuberculomas, third ventricular tuberculoma is extremely rare. Only one case of third ventricular tuberculoma has been reported in the literature so far [5] and this is the second one that is being presented here.


  Case Report Top


A 21-year-old right-handed girl was brought to the emergency department with a history of sudden onset of unconsciousness for the last 6 h. The family members gave a history that she had been suffering from persistent headache and occasional vomiting for the last 3 months. On examination, she had GCS of 13 with bilateral papilloedema on funduscopy. There were no cranial and motor deficits. She was subjected to emergent cranial computed tomography (CT) scan. Plain CT scan of the brain revealed third ventricular mass with obstructive hydrocephalus [Figure 1]a. Biventricular peritoneal shunt (Chhabra medium pressure) was performed as an emergency procedure. Ventricular catheters were placed in the left frontal horn at Kocher's point and in the right occipital horn at Frazier's point, and both were connected by a “Y” connector. Post-operatively, after ventriculoperitoneal shunt, she regained her conscious level and had no neurological deficit. The cerebrospinal fluid (CSF) sample that was collected during the shunting procedure was normal and there was no bacterial growth on culture of CSF. Post-operative CT scan of the brain showed decreased sizes of the ventricles [Figure 1]b. Her chest X-ray was unremarkable. Hematology and biochemistry were within normal limits. Serological test for HIV and hepatitis were negative. Magnetic resonance imaging (MRI) of the brain was carried out 1 week after the CSF diversion surgery, and it depicted third ventricular mass obstructing the Foramen of Monro, which was isointense on T1W and hypointense on T2W images. The lesion was homogenously enhanced after intravenous gadolinium injection [Figure 2]a and [Figure 2]b. On clinical and radiological grounds, the diagnosis was made as neoplasm that could be a glial tumor, lymphoma or colloid cyst. Right frontal craniotomy and transcallosal, transventricular total excision of the tumor was performed. The tumor was smooth and round, firm in consistency, moderately vascular and attached to the Foramen of Monro [Figure 3]. The tumor was not breakable and not suckable, and was therefore removed as a single piece. The per-operative and post-operative periods were uneventful. After surgery, the patient had smooth neurological recovery and she was mobilized on the third post-operative day. Surprisingly, histological examination revealed granulomatous lesion with epitheloid and Langhans cells, consistent with tuberculoma [Figure 4]. Antituberculous drugs were started. Before discharge, MRI of the brain with intravenous contrast was ordered, and it showed no evidence of residual lesion, and Foramen of Monro was opened up [Figure 2]c. She was followed-up at 1 and 3 months at the neurosurgical OPD, and her neurological status was normal and had resumed her normal life.
Figure 1: (a) Pre-operative plain axial computed tomography (CT) scan demonstrating isodense lesion in the anterior third ventricle with obstructive hydrocephalus. (b) Post VP shunt CT scan of the brain of the same patient

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Figure 2: (a) Pre-operative magnetic resonance imaging (MRI) with sagittal cut after contrast showing well-enhanced third ventricular mass. (b) Post-operative MRI with contrast revealed on residual mass

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Figure 3: Surgical specimen, the mass was round, has smooth surface and firm in consistency, gray- white appearance upon sectioning

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Figure 4: Photomicrograph (H and E, ×160) showing Langhans giant cells and epitheloid cells that are characteristic features of tuberculoma

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  Discussion Top


Tuberculosis of CNS has several clinical manifestations such as meningitis, epidural and subdural abscess formation and intracranial tuberculoma. Tuberculomas generally develop independent of tuberculous meningitis. However, the rupture of a tuberculoma may arise during the treatment of meningitis. The incidence of coexistent CNS tuberculoma and tuberculous meningitis is between 10% and 50%.[4],[6] Tuberculomas are primarily located in the cerebral hemisphere, although tuberculomas have been found in the pituitary stalk,[1] sellar and suprasellar regions,[7],[8],[9] corpus callosum,[10] cavernous sinus,[11],[12],[13] brainstem,[14],[15],[16],[17],[18] cerebellum [19],[20] and intraventricular.[21],[22],[23] Intraventricular tuberculomas are rare, and, among them, third ventricular tuberculoma is very rare; only one case has been reported in the literature.[5]

Routine hematologic evaluation, including total count and ESR, is often unremarkable in patients with intracranial tuberculomas. Examination of CSF is the most important laboratory analysis in the evaluation of tuberculous meningitis, but it is usually unhelpful in the evaluation of intracranial tuberculomas.[3] MRI is clearly superior to CT scan for all cases of intracranial tuberculomas.[24] MRI with gadolinium enhancement is usually the study of choice, although CT may be preferred before an emergency lumber puncture to rule out tuberculoma as a risk of brain herniation. The imaging characteristics of tuberculomas depend on their age, their viability and the presence of caseous necrosis or calcification. In an early granuloma with a viable center, a non-contrast CT may reveal a hypodense, isodense or even a slightly hyperdense area. After administration of contrast, the CT may show homogenous or ring-like enhancement.[25],[26] On MRI, tuberculomas are usually hypointense on T1W or T2W images, although the center may be hyperintense on the latter. However, gadolinium-enhanced MRI usually reveals marked homogenous or ring enhancement.[27],[28] MR spectroscopy may increase the specificity of diagnosis by identifying lipids within the lesion that one considered characteristic for tuberculoma, and has shown elevated lipid peaks within tuberculous lesions. Thus, MR spectroscopy may safely avoid the need of brain biopsy to confirm the nature of the lesion.[29] However, this imaging facility is not available in our institute at present.

This is the second case of histologically proven third ventricular tuberculoma, and the first such case was described by Singh JP and Chandy MJ in 1988.[5] In a 13-year-old girl, they had found enhancing third ventricular mass with obstructive hydrocephalus. After putting a unilateral left-sided ventriculoperitoneal shunt, they had partially excised the mass through a right frontal craniotomy and transcortical, transventricular approach, and biopsy proved to be as tuberculoma. Post-operatively, the girl did excellent recovery with a course of antituberculous drugs.

Third ventricular mass without evidence of tuberculous infection elsewhere in the body should undergo surgical excision, either transcallosal, transventricular or transcortical, or transventricular, which provides the histological diagnosis and creates a normal CSF pathway. Total excision is desirable so that the shunt system can be removed in the future in case of shunt complications like malfunctioning of shunt and infection, and the patient can be made shunt independent.

Surgical excision and a course of antituberculous drugs for 16-18 months are usually sufficient to cure such tuberculoma.

Tuberculoma should be kept in mind as one of the differential diagnoses along with primary and secondary neoplasms in any enhancing third ventricular mass, particularly in immunocompromised personnel and in patients from underdeveloped countries where tuberculosis is endemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Stalldecker G, Diez S, Carabelli A, Regnoso R, Rey R, Hofmann N, et al. Pituitary stalk tuberculoma. Pituitary 2002;5:155-62.  Back to cited text no. 1
    
2.
Dye C, Scheele S, Dolin P, Pathania V, Raviglione MC. Consensus statement. Global burden of tuberculosis: Estimated incidence, prevalence and mortality by country. WHO Global Surveillance andmonitoring project. JAMA 1999;282:677-86.  Back to cited text no. 2
    
3.
Cannard KR. Tuberculous meningitis and tuberculoma. In: Osenbach RK, Zeidman SM, editors. Infections in neurological surgery. Philadelphia: Lippincott-Raven Publishers; 1999. p. 23-40.  Back to cited text no. 3
    
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Bayindir C, Mete O, Bilgic B. Retrospective study of 23 pathologically proven cases of central nervous system tuberculomas. Clin Neurol Neurosurg 2006;108:353-7.  Back to cited text no. 4
    
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Singh JP, Chandy MJ. Third ventricular tuberculoma: A case report. Br J Neurosurg 1988;2:93-6.  Back to cited text no. 5
    
6.
Anuradha HK, Garg RK, Sinha MK, Agarwal A, Verma R, Singh MK, et al. Intracranial tuberculomas in patients with tuberculous meningitis: Predictors and prognostic significance. Int J Tuberc Lung Dis 2011;15:234-9.  Back to cited text no. 6
    
7.
Behari S, Shinghal U, Jain M, Jaiswal AK, Wadwekar V, Das KB, et al. Clinicoradiological presentation, management options and review of sellar and suprasellar tuberculomas. J Clin Neurosci 2009;16:1560-6.  Back to cited text no. 7
    
8.
Furtado SV, Venkatesh PK, Ghosal N, Hedge AS. Isolated sellar tuberculoma presenting with panhypopituitarism: Clinical diagnostic considerations and literature review. Neurol Sci 2011;32:301-4.  Back to cited text no. 8
    
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Nayil K, Singh S, Makhdoomi R, Ramzan A, Wani A. Sellar-suprasellar tuberculomas in children: 2 cases and literature review. Pediatr Neurol 2011;44:463-6.  Back to cited text no. 9
    
10.
Fath-Ordoubandi F, Lane RJ, Richards PG. Histological surprise: Callosaltuberculoma presenting as malignant glioma. J Neurol Neurosurg Psychiatry 1997;63:98-9.  Back to cited text no. 10
    
11.
Al Soub H, Al Alousi FS, Al-Khal AL. Tuberculoma of cavernous sinus. Scand J Infect Dis 2001;33:868-70.  Back to cited text no. 11
    
12.
Boutarbouch M, Arkha Y, Gana R, El Maguili MR, Bellakhdar F. Tuberculoma of cavernous sinus mimicking a meningioma: A case report and review of literature. J Neurol Sci 2009;278:123-6.  Back to cited text no. 12
    
13.
Guseinov GK, Magomedov MS. A case of brain cavernous tuberculosis. Probl Tuberk Bolezn Legk 2009;6:46-8.  Back to cited text no. 13
    
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Akhaddar A, Mahi M, Harket A, Elmostarchid B, Belhachemi A, Elasri A, et al. Brainstem tuberculoma in a postpartum patient. J Neuroradiol 2007;34:345-6.  Back to cited text no. 14
    
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Enani M, Al-Nakhli DJ, Bakhsh E. Isolated brainstem tuberculoma presenting with one and a half syndrome. Saudi Med J 2006;27:1407-11.  Back to cited text no. 15
    
16.
Rajshekhar V, Chandy MJ. Tuberculomas presenting as isolated intrinsic brainstem masses. Br J Neurosurg 1997;11:127-33.  Back to cited text no. 16
    
17.
Sharif M, More V, Puvandare S. Brainstem tuberculoma: Presenting as Millard Gublar Syndrome. Indian J Pediatr 2010;77:707.  Back to cited text no. 17
    
18.
Verma R, Sharma P. Lateral medullary syndrome due to brainstem tuberculoma. J Assoc Physicians India 2011;59:382-4.  Back to cited text no. 18
    
19.
Ranjan M, Saritha A, Mahadevan A, Shankar SK, Sampath S. Cerebellertuberculoma presenting as haematoma: A case report and pathophysiological consideration. Br J Neurosurg 2009;23:203-5.  Back to cited text no. 19
    
20.
Tanioka D, Abe T, Ikeda H, Kushima M. A case of cerebellar tuberculoma. No Shinkei Geka 2005;33:919-23.  Back to cited text no. 20
    
21.
Berthier M, Sierra J, Leiguarda R. Intraventricular tuberculoma. Report of four cases in children. Neuroradiology 1987;29:163-7.  Back to cited text no. 21
    
22.
Desai K, Nadkarni T, Bhatjiwale M, Goel A. Intraventricular tuberculoma. Neurol Med Chir (Tokyo) 2002;42:501-3.  Back to cited text no. 22
    
23.
Hsu PW, Lin TK, Chang CN. Solitary intraventricular tuberculoma in adult. Acta Neurochir (Wien) 2004;146:1151-3.  Back to cited text no. 23
    
24.
Gupta RK, Jena A, Singh AK, Sharma A, Puri V, Gupta M. Role of magnetic resonance (MR) in the diagnosis and management of intracranial tuberculomas. Clin Radiol 1990;41:120-7.  Back to cited text no. 24
    
25.
Bhargava S, Tandon PN. Intrcranial tuberculomas: A CT study. Br J Radiol 1980;53:935-45.  Back to cited text no. 25
    
26.
Welchman JM. Computerised tomography of intracranial tuberculomata. Clin Radiol 1979;30:567-73.  Back to cited text no. 26
    
27.
Salgado P, Del Brutto OH, Talamas O, Zenteno MA, Rodriguez-Carbajal J. Intracranial tuberculoma: MR imaging. Neuroradiology 1989;31:299-302.  Back to cited text no. 27
    
28.
Sonmez G, Ozturk E, Sildiroglu HO, Mutlu H, Cuce F, Senol MG, et al. MRI findings of intracranial tuberculomas. Clin Imaging 2008;32:88-92.  Back to cited text no. 28
    
29.
Vagueiro Rodriguez J, Martinez-Varquez C, Martinez-Cueto P, Sopena Perez-Arguelles B, Portela Orjales D. Utility of magnetic resonance spectroscopy for the non-invasive diagnosis of cerebral tuberculomas. Rev Clin Esp 2009;209:405-6.  Back to cited text no. 29
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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