Issue 2, Vol 1, Jan 2017

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T uberculosis is a major public health challenge in PNG. TB, as it is inevita-

bly abbreviated, can present as a disease in any organ, from skin to brain

and is a common cause of ‘Fever of unknown origin( FUO)’.

Pulmonary Tuberculosis is highly infective and today resistance to

primary anti-tubercular drugs is becoming increasingly common. Multidrug

Resistant Tuberculosis( MDR) and Extremely Drug Resistant Tuberculosis( XDR)

have become Public Health nightmares and put patients, families and health

workers at great risk.

Fortunately this young child with Tuberculosis of the brain, who presented to

PIH nine months late, had a quick response and a successful outcome.

Our congratulations to Dr. Baki, Dr Khine, our radiology department and nursing staff who managed the patient’s

evaluation and treatment.

Dr Venkita Suresh

Medical Director

From The Editor’s Desk

A case of TUBERCULOMA of the BRAIN | Dr Baki & Dr Kway Khine

Case scenario A 3-year-old boy was referred from Lihir Medical Centre (ISOS) for further

evaluation and management.

Patient presented with headache, abnormal gait and right upper limb weakness

since March 2016. No other neurological complaint was noted. He could

understand when talked to, but did not speak. There was no history of fever,

cough, night sweats. No history of allergy to medicines.

No significant medical/surgical condition in the past.

He had a normal birth history. He is the only child

to the parents.

Maternal uncle had tuberculosis many years ago and completed anti-TB treatment.

On examination: No distress/lethargy/pallor/cyanosis, Body weight – 13.5 kg

Vital signs: HR – 100/min, RR – 30/min, SPO2 – 100% on room air, Temperature – 36C

Dr Kway with the patient

Dr MJ Baki

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Examination of CNS GCS 15/15, no neck stiffness.

“down and out” left eye. Ptosis, Lt Eye, present on admission

Pupils: 5 mm in left eye, 3 mm in right eye

Fundoscopy: No signs of papilledema

Motor :

Tone – Normal

Power – Right upper limb 2/5, Other limbs – 5/5

Reflexes – Normal

Sensory : intact

Cerebellar signs were difficult to elicit in the child; gait and

coordination difficult to evaluate. No nystagmus

Other systemic examinations were unremarkable.

Provisional Diagnosis Admitted to ward under the care of Dr. Mary Baki (consultant paediatrician) with provisional diagnosis of

space occupying lesion (Tuberculoma/glioma).

Investigations

X ray of the Chest

Cluster of

ring-enhancing

lesions in

right cerebellum

Issue 2, Vol 1, Jan 2017 3

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CT scan of brain with contrast was performed on him and revealed right cerebellar and subcortical tuberculomas

with cerebral oedema, positive mass effect and obstructive lateral ventriculomegaly. Hence, chest X ray and

Quantiferon Gold TB test were done, which revealed positive for Tuberculosis.

Complete blood count showed neutrophilia (67.70%) with normal total counts

Cryptococcal antigen was negative

CT scan showed cluster of ring-enhancing lesions in right cerebellum, with larger lesion being 43.5x31.3 mm

Treatment He was then commenced on anti-TB medications as follows:

Rifampicin 15 mg/kg (200 mg) daily

Isoniazid 10 mg/kg (150 mg) daily

Pyrazinamide 35 mg/kg (500 mg) daily

In addition to anti-TB medications, steroids (IV dexamethasone) 2 mg was given 8 hourly for 3 days, then reduced

to 12 hourly for 2 days and once daily for another 2 days. Then it was changed to oral form (prednisolone) with the

dose of 1 mg/kg for a month.

Unfortunately, he did not have ophthalmologist assessment as in-house ophthalmologist was on leave and attempts

at bringing in a visiting specialist consultant were unsuccessful. With on-going treatment, his condition swiftly

improved; he was putting on weight and mobilizing more steadily.

Discussion Tuberculomas are a rare and serious form of tuberculosis of the Central Nervous System ( CNS) due to haematog-

enous spread of Mycobacterium Tuberculosis. CNS TB usually has signs and symptoms of increased intracranial

pressure or space-occupying lesions in the brain or spine. Common complaints may include headache, stiff neck,

fever, weight loss, blurry vision, confusion, lethargy, nausea/vomiting. Patients with tuberculomas will have a

physical examination that is consistent with location in the brain of the space-occupying lesion, which may include

cranial nerve deficits, altered mental status, visual changes, hemiparesis or seizures.

Surgical intervention for intracranial tuberculomas is generally not recommended because antitubercular therapy

of appropriate duration, combined with corticosteroids, is usually effective. However, surgery may be required if

immediate decompression is necessary or if biopsy is needed for definitive diagnosis.

CDC guidelines recommend a 9-12 month pharmacologic treatment regimen for CNS TB.

Initial phase – 2 months of isoniazid, rifampicin, pyrazinamide, ethambutol (not recommended in paediatric cases)

Continuation phase – 7-10 months of isoniazid and rifampicin

Development of intracranial lesions while on anti-TB therapy should not be considered a failure of treatment.

Rather, treatment should be continued for a prolonged course, and high-dose corticosteroids added to the regimen.

Treatment regimen for special conditions such as (for patients with HIV, renal or liver diseases) can be found at the

CDC website. (www.cdc.gov)