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183]

E-JCRT Correspondence

Intracranial tuberculoma mimicking brain

metastasis
ABSTRACT
To our knowledge, this is the first report of an intracranial tuberculoma in an immunocompetent patient with a solid primary tumor outside
the central nervous system. This case is important because the patient underwent treatment for a presumed brain metastasis, based on
the knowledge that a solid extracranial primary tumor was present, but before the brain lesion pathology was determined.
KEY WORDS: Brain metastasis, central nervous system, intracranial tuberculomas, tuberculosis

INTRODUCTION
In developed countries, about 4% of central nervous
system (CNS) lesions are caused by tuberculosis (TB).
Accurate diagnosis is the first step in the journey
towards a successful patient outcome, but this
becomes difficult in the absence of extracranial TB,
as seen in the case we report here. Many cases of
CNS tuberculoma (CNST) that resemble intracranial
tumors on imaging have been reported, but a solid
primary tumor (SPT) at diagnosis was absent in all
of them, and treatment was postponed until the
brain lesion pathology was determined.
CASE REPORT
A 51yearold woman complained of a sore under
her tongue. She had had difficulty chewing and
speaking, with pain in the anterior mandibular
teeth area, sore throat, episodic numbness on
the left side of the face, neck, tongue, gums, and
lip during the preceding month, and a 15pound
weight loss over four months. She denied having
fever, chills, night sweats or productive cough. She
had a history of heavy ethanol use and 30 packs of
cigarettes per year.
A b i o p s y o f t h e m o u t h l e s i o n re v e a l e d
moderatetopoorly differentiated squamous
cell carcinoma(stage T2N1M0). T1weighted
magnetic resonance(MR) images obtained one
month after the oral lesion biopsy revealed an
edematous gadolinium contrastenhancing mass
(maximal diameter 2.3cm) in the right cerebellar
hemisphere, extending to the tentorium and
showing characteristics[Figure1a] typical
of a brain metastasis (BM) [Figure1b]. The
T2weighted magnetic resonance imaging(MRI)

scan showed hypodensity within the center of

the mass, with surrounding edema. This was
consistent with a necrotic mass with surrounding
edema and was also suggestive of a BM. The
positron emission tomography(PET) scan revealed
fluorodeoxyglucose(FDG)avid disease in the
floor of the mouth and right cerebellum. No
MR spectroscopy was performed. The patient
had no neurological symptoms in the cerebellar
mass diagnosis. She was immunocompetent and
tested negative for human immunodeficiency
virus(HIV). Headache and ataxia symptoms
appeared 20days after the detection of the mass.
Therefore, resection of the probable metastasis
was indicated. Preoperative MR imaging showed
no change in size.

Abhijit L.
Salaskar,
Wael Hassaneen,
Cheryl H.
Keenan,
Dima Suki
Department of
Neurosurgery, The
University of Texas
MD Anderson Cancer
Center, Houston,
Texas, USA
For correspondence:
Dr. DimaSuki,
Department of
Neurosurgery,
Unit442, The
University of Texas
MD Anderson
Cancer Center,
1400 Holcombe
Blvd, Houston,
Texas77030, USA.
Email:dsuki@
mdanderson.org

The neurosurgery was uneventful, the cerebellar

mass was completely resected[Figure1c], and the
patients neurological symptoms resolved.
The resected mass was found to be a necrotizing
granuloma[Figure1d]. There were no malignant
cells, but round yeast cells[diameter 5-6
micrometers; Figure1e] were detected, consistent
with the presence of blastomyces, prompting
treatment with voriconazole. After the diagnosis
of blastomycosis, the patient had a chest computer
tomography (CT) scan, which was negative, a
transthoracic echocardiogram, which was negative
for cardiac vegetations, and the subsequent blood
cultures were also negative. Followup MR images
four weeks later showed a new 3mm enhancing
lesion in the left occipital lobe. Although an acidfast bacillus (AFB) smear with Ehrlich ZiehlNelsons
staining did not detect acidfast bacilli in the
original resected lesion, a culture from it on the
LowensteinJensen medium grew Mycobacterium

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DOI: 10.4103/0973-1482.138131
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Salaskar, etal.: Intracranial tuberculoma mimicking brain metastasis

Figure 1: (a) Preoperative contrast-enhanced T1-weighted axial MRI of the brain showing a right cerebellar ring-enhancing lesion resembling a
metastatic lesion, (b) Preoperative contrast-enhanced T1-weighted axial MRI of the brain showing a histologically proven brain metastasis in the
right cerebellar hemisphere, (c) T1-weighted axial MRI of the brain showing the resection cavity with no evidence of enhancement, (d) Histologic
section from the resected cerebellar mass showing multiple granulomas composed of epithelioid histiocytes, lymphocytes, and Langhans giant
cells. (x100 magnification), (e) Gomori methenamine silver (GMS) stain showing round yeast (arrow) of a uniform 5 to 6 micrometers in diameter.
The morphology of the microorganisms is consistent with blastomyces a period

tuberculosis five weeks later. Reinvestigation of the patients

history revealed close contact with a family member with
active TB.
The patient underwent an intensive twomonth course
of quadruple antituberculosis chemotherapy (isoniazide,
rifampin, ethambutol, pyrazinamide), with control of the
intracranial TB. Resection of the oral cavity lesion was
performed along with bilateral selective cervical lymph
node dissection. The MR images obtained six months
after antituberculosis chemotherapy initiation showed
no evidence of local or distant recurrence of the resected
cerebellar lesion and a stable nonenhancing left occipital
lesion. Antituberculosis chemotherapy was administered
for nine months after CNST diagnosis. Twelve months after
the cerebellar mass resection, the patient succumbed to
metastases to the trachea, mediastinum, and lung.
DISCUSSION
Central nervous system involvement occurs in 10-15% of the
patients with TB. Tuberculous meningitis is the most frequent
manifestation of CNS TB, followed by CNST and tuberculous
abscess. CNSTs constitute approximately 4% of the intracranial
masses seen in developed countries and 15-30% of those in
developing countries. They are usually solitary, with 15-34%
being multiple.

Often, the findings of a primary TB infection are absent. Our

patient showed no fever, chills, night sweats or productive
cough. CNST is challenging to diagnose, because it mimics other
infectious and noninfectious medical conditions, especially in
asymptomatic patients. Moreover, its imaging characteristics
with CT and MR imaging resemble those of other intracranial
focal lesions. As assessed by CT morphology alone, a solitary
CNST may be indistinguishable from an abscess(pyogenic or
fungal), a tumor or another ringenhancing lesion.
Magnetic resonance imaging findings of CNST depend on
whether the tuberculoma is caseating or noncaseating. Asolid
caseating granuloma may appear isointense or hypointense
on T1weighted MR images and hypointense on T2weighted
images - a hypointensity that corresponds with solid caseation
necrosis[Figure1b], and these lesions typically show ring
enhancement.[1] Noncaseating granulomas appear hypointense
on T1weighted MR images and hyperintense on T2weighted MR
images,[2] but there is considerable overlap with other intracranial
focal lesions(e.g.,fungal granulomas, primary, and metastatic
neoplasms). Caseating and fungal granulomas have high iron
and manganese levels, causing hypointensity on T2weighted MR
images. However, they can be differentiated based on different
resonance patterns using invivo proton MR spectroscopy.[3]
Positron emission tomography (PET) was used to
identify FDGavid disease in the floor of the mouth and

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Salaskar, etal.: Intracranial tuberculoma mimicking brain metastasis

cerebellum, supporting a diagnosis of BM rather than

CNST. Nevertheless, FDG is not a cancerspecific agent,
and intense uptake of FDG may occur on PET scans in
patients having infectious diseases(mycobacteria, fungi,
bacteria), sarcoidosis or radiation pneumonitis. In contrast,
adenomas, broncholoalveolar carcinomas, carcinoid
tumors, lowgrade lymphomas, and small tumors have
low glycolytic activity, leading to falsenegative results
on PET scans.[4]
Even as the AFB smear failed to detect acid-fast bacillus, the
culture for M.tuberculosis was positive after five weeks, leading
to a final diagnosis of tuberculoma. As the number of bacilli
the CNST varied with the degree of immunosuppression, the
patients immunocompetent status could explain the negative
result of the AFB smear.
The patient developed headache and ataxia one month after
detection of the suspected Resection was performed to relieve
the intracranial pressure. Had she been asymptomatic, based
on the brain mass size, she probably would have undergone
stereotactic radiosurgery, unnecessarily exposing her to
radiation side effects.
Central nervous system tuberculoma, although rare, must be
included in the differential diagnosis when an intracranial
mass is detected, even when an extracranial solid primary
tumor is noted. If a patients clinical presentation
includes risk factors/conditions for TB, such as human
immunodeficiency virus(HIV) infection, intravenous drug
use, alcohol use, aggressive chemotherapy, transplantation,
active TB contact, or overcrowding, there may be a reason
to suspect CNST. In our study, CNST was not suspected
because the patient was immunocompetent and lacked TB
symptoms, although the presence of an active TB family
contact and her history of heavy alcohol use should have
been illuminating.

In asymptomatic patients in whom an intracranial mass is

highly suspected of being non neoplastic, stereotactic biopsy is
preferred because of its 85% diagnostic efficacy when followed
by paraffin sectioning and histopathological examination.[5]
This less invasive method may prevent misdiagnosis of the
lesion as a BM, mitigating the need for unnecessary treatments
like radiotherapy. Once a CNST diagnosis is confirmed,
conventional antituberculosis chemotherapy is the preferred
treatment. Resection must be reserved for cases with
symptomatic CNST and antituberculosis chemotherapy failure.
ACKNOWLEDGMENT
The authors would like to acknowledge Dr.David Wildrick for editorial
assistance.

REFERENCES
1. GuptaRK, HusainM, VatsalDK, KumarR, ChawlaS, HusainN.
Comparative evaluation of magnetization transfer MR imaging and
in vivo proton MR spectroscopy in brain tuberculomas. Magn Reson
Imaging 2002;20:37581.
2. GuptaRK, PandeyR, KhanEM, MittalP, GujralRB, ChhabraDK.
Intracranial tuberculomas: MRI signal intensity correlation with
histopathology and localised proton spectroscopy. Magn Reson
Imaging 1993;11:4439.
3. GuptaRK, PoptaniH, KohliA, ChhabraDK, SharmaB, GujralRB. Invivo
localized proton magnetic resonance spectroscopy of intracranial
tuberculomas. Indian J Med Res 1995;101:1924.
4. ChangJM, LeeHJ, GooJM, LeeHY, LeeJJ, ChungJK, etal. False positive
and false negative FDGPET scans in various thoracic diseases. Korean
J Radiol 2006;7:5769.
5. MohantyA, SantoshV, AnandhB, KolluriVR, VasudevMK, HegdeT,
etal. Diagnostic efficacy of stereotactic biopsies in intracranial
tuberculomas. Surg Neurol 1999;52:2528.
Cite this article as: Salaskar AL, Hassaneen W, Keenan CH, Suki D.
Intracranial tuberculoma mimicking brain metastasis. J Can Res Ther
2015;11:653.
Source of Support: Nil, Conflict of Interest: None declared.