ISSN - 0973-0958

Pediatric Oncall Journal



Dr Ira Shah.
Medical Sciences Department, Pediatric Oncall, Mumbai, India.

Dr Ira Shah, Medical Sciences Department, Pediatric Oncall, 1, B Saguna, 271, B St. Francis Road, Vile Parle {W}, Mumbai 400056.
Clinical Problem
Case Report: A 7 years old boy presented with scholastic backwardness since 5 months, headache since 10 days, projectile vomiting since 5 days and right sided focal convulsion with fever today. There was no loss of consciousness or altered sensorium. There was no history of previous exposure to Tuberculosis. His elder brother had died at the age of 2 years due to liver disease. On examination, his growth was normal (Height = 114 cm, Weight = 17.5 kg), and had neck stiffness. CNS examination showed normal tone and power with right sided ataxia, brisk reflexes on right side and right sided extensor planters. Other systemic examination was normal. He was thus suspected to have an intracranial space occupying lesion (SOL). An MRI brain showed large thick peripherally enhancing lesion in right occipital lobe measuring 3.0 x 2.2 x 3.0 cm and similar lesions in bilateral medial temporal lobes, right posterior temporal lobe and left occipital lobe anteriorly, hypointense on T1 & hyperintense on T2 with cerebellar tonsillar herniation suggestive of multiple intracranial SOLs. Workup for malignancy in form of VMA, alpha fetoprotein and beta-HCG was negative. CSF showed 18 lymphocytes/cumm with normal sugar and high proteins (1.7 gm%). X-Ray Chest showed left parahilar haziness and Mantoux test was positive (17 x 15 mm). CSF TB PCR was negative.

What is the etiology of the SOL?
Expert's opinion:
Though tuberculous meningitis is the commonest presentation of neurotuberculosis, tuberculomas in the central nervous system which present clinically as brain tumor are also another manifestation of neurotuberculosis. Tuberculomas account for upto 40% of brain tumors over the world. In children, tuberculomas are infratentorial, located at the base of the brain near the cerebellum, often singular but may be multiple. In adults, they are most often supratentorial. The most common symptoms are headache, fever and convulsions. The tuberculin test (Mantoux test) is usually reactive but chest radiograph is usually normal. Neuroimaging by CT or MRI of the brain help to determine the diagnosis. Tuberculomas usually appear as discrete lesions with significant perilesional edema and contrast enhancement leading to ring like lesion. Occasionally, surgical excision may be necessary to distinguish tuberculoma from other causes of brain tumor. CSF may show presence of characteristic findings or may be normal and PCR may be not be sensitive to pick up Tuberculosis. Treatment consists of 4 antituberculous drugs for 2 months followed by Isoniazid (INH) & Rifampicin for next 10 months. Corticosteroids decrease mortality rate as well as long-term neurologic sequelae by reducing vasculitis, inflammation and intracranial pressure.

1) Munoz FM, Starke JR. Tuberculosis (Mycobacterium tuberculosis). Eds: Behram RE, Kliegman RM, Jenson HB. In: Nelson’s Textbook of Pediatrics, 17th edn. Saunders. Philadelphia. 2004:958-970.
Compliance with ethical standards
Funding:  None  
Conflict of Interest:  None
Cite this article as:
Shah I. INTRACRANIAL SOL. Pediatr Oncall J. 2006;3: 36.
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