Multiple Intracranial Tuberculomas In Immunocompetent Patient: An Uncommon Primary Manifestation Of Central Nervous System Tuberculosis (CNS TB)

Tuberculosis (TB) is a serious yet potentially-curable health issue among most developing countries including Pakistan. We report the case of an immunocompetent patient having multiple intracranial tuberculomas without evidence of meningitis which is an uncommon manifestation of CNS tuberculosis. A 50-year old man presented with 5 episodes of tonic-clonic generalized fits for 1 day, right sided body weakness for 2 weeks, generalized headaches and intermittent low-grade fever for 1 month. No contact or past history of tuberculosis was reported. On neurologic examination, there was hypertonia, exaggerated deep tendon reflexes and power of 3/5 in both right upper limb and right lower limb with a right plantar extensor response. CT scan (Brain) showed hyperdense areas in left frontal and temporal lobes with surrounding vasogenic edema. ESR was raised at 86 mm/hour. CSF analysis demonstratedRBC 0 cells/uL, WBC 783 cells/uL with 100% lymphocytes, Glucose 39 mg/dl andProtein 81 mg/dl with negative organism microscopy onAFB and Giemsa staining. However, CSF was positive for GeneXpert-PCR-MTB but drug resistance was not detected to rifampicin. Brain MRI with FLAIR demonstrated multiple disseminated, rim enhancing lesions with perilesional edema in bilateral cerebral hemispheres, thalami, left basal ganglia, medulla oblangata and cerebellum having no meningeal enhancement. Workup for immune-suppression was normal. A diagnosis of multiple intracranial tuberculomas was established and Anti-tubercular therapy was commenced. He was asymptomatic and taking ATT with good compliance having no adverse affects by 6-week follow up.