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Tuberculoma of the brain: A series of 16 cases treated with anti-

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INT J TUBERC LUNG DIS 11(1):91–95
© 2007 The Union

Tuberculoma of the brain: a series of 16 cases treated with

anti-tuberculosis drugs

M. N. A. Idris,* T-E. O. Sokrab,*† M. A. R. Arbab,* A. E. M. Ahmed,* H. El Rasoul,* S. Ali,*

M. A. Elzubair,* S. M. Mirgani*
* Faculty of Medicine, University of Khartoum, Khartoum, Sudan; † Hamad General Hospital, Doha, Qatar

SUMMARY

OBJECTIVES: To describe the clinical presentation, ra-
diological findings and outcome of treatment with anti-
tuberculosis drugs in 16 cases of intracranial tuberculoma.
D E S I G N : Consecutive cases admitted with tuberculoma
to the National Center for Neurological Diseases in Khar-
toum, Sudan, were included in the study. The diagnosis
was based on clinical and neuro-imaging features and re-
sponse to anti-tuberculosis treatment. Histopathology
of material from the brain or other extracranial tissues
was available in seven cases.
R E S U L T S A N D C O N C L U S I O N S : The commonest present-
ing features were headache (100%), generalized convul-
sions (68.7%) and hemiparesis (56.2%). Computerised
axial tomography/magnetic resonance imaging (CT/MRI)
showed single or multiple lesions that showed intense
contrast enhancement and perilesional edema. The lesions
completely cleared on anti-tuberculosis treatment in the
majority of survivors (13/15). Partial clearance of lesion
was associated with late presentation, multiple large le-
sions and advanced miliary disease. We advocate early
empirical trial of anti-tuberculosis drugs for intracranial
tuberculoma even after a presumptive diagnosis, partic-
ularly in areas where the infection is endemic.
K E Y W O R D S : intracranial tuberculoma; anti-tuberculo-
sis drugs; Sudan

TUBERCULOSIS (TB) continues to be a major health
problem in developing countries. Fast and growing
global migration of population and associations with
human immunodeficiency virus (HIV) infection have
led to a resurgence of TB in industrialized countries.
Involvement of the nervous system is commonly man-
ifested by tuberculous meningitis, tuberculoma or brain
abscess. In developing countries, the incidence of tuber-
culoma varies from 5% to 30.5% of all intracranial
space occupying lesions.1,2
Tuberculomas are granulomatous mass lesions com-
posed of a central zone of caseation surrounded by a
collagenous tissue capsule arising in the brain paren-
chyma or the spinal cord. Lack of specific clinical and
imaging characteristics often makes confident diag-
nosis of tuberculoma difficult to establish, particu-
larly in the absence of extracranial lesions and his-
tological data.3,4 For this reason, especially in areas
with high disease prevalence, an empirical trial of anti-
tuberculosis therapy containing potent drugs such as
rifampicin (RMP) is advocated.5 Only a high index of
suspicion or a presumptive diagnosis based on typical
clinical and neuro-image findings suffices to warrant
such treatment.
In this paper we present the clinical and neuro-
image findings in 16 patients with brain tuberculoma
and describe a favorable outcome on medical treatment
alone.
MATERIALS AND METHODS
Sixteen patients, 10 females and 6 males, aged 17–
60 years (mean 37  12.6) were admitted with intra-
cranial tuberculoma to the National Center for Neuro-
logical Diseases in Khartoum, Sudan, between March
1999 and February 2005. The center incorporates a
specialized hospital with well-established neurology and
neurosurgery units. The diagnosis of tuberculoma was
considered definite when histopathological and/or bac-
teriological evidence of Mycobacterium tuberculosis
was available. A probable diagnosis was based on typ-
ical imaging features of the lesions and a clearly favor-
able response to drug treatment.
Following detailed clinical examination, the patients
were subjected to investigations and screening. The fol-
lowing tests were performed: blood counts and eryth-
rocyte sedimentation rate (ESR), chest X-ray (CXR),
tuberculin test (1 tuberculin unit [TU] of purified pro-

Correspondence to: Professor Tag-Eldin O Sokrab, MD, PhD, Department of Neurology, Hamad General Hospital, P O Box
3050, Doha, Qatar. Tel: (974) 580 2096. Fax: (974) 439 2768. e-mail: tosokrab@yahoo.com
Article submitted 31 March 2006. Final version accepted 17 August 2006.
92 The International Journal of Tuberculosis and Lung Disease

Table 1 Symptoms and signs in 16 patients with RESULTS

intracranial tuberculoma
Clinical presentation
Symptom or sign Patient n (%)
The presenting symptoms and signs are summarized
Headache 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 16 (100) in Table 1. The commonest presenting symptoms were
11, 12, 13, 14, 15, 16
Convulsions 1, 2, 3, 5, 6, 9, 10, 11, 12, 11 (68.7) headache (100%), partial or generalized convulsions
13, 14 (68.7%) and hemiparesis with or without hemisen-
Papilledema 1, 2, 3, 4, 5, 6, 8, 9, 11 9 (56.2) sory symptoms (56.2%). Increased intracranial pres-
Hemiplegia with or without 1 (L), 7 (R), 9 (R), 10 (R), 9 (56.2)
hemisensory symptoms 11 (L), 15 (R), 16 (L) sure leading to papilledema was encountered in nine
Fever 6, 8, 10, 11, 14, 16 6 (37.5) patients (56.2%). Fever (37.5%) was not common in
Dysphasia 7, 9, 12 3 (19.7) patients who only had intracranial tuberculoma, but
Cranial nerve palsy 6 (VI), 10 (III), 11 (VI) 3 (19.7)
Neck stiffness 6, 10 2 (12.5) often occurred in those with other systemic manifes-
Memory disturbance 2, 9 2 (12.5) tation or who had a previous close contact with a
Choroid tubercles 6 (R eye) 1 (6.2) TB case. The duration of symptoms at presentation
Paraplegia 6 1 (6.2)
Cerebellar ataxia 6 1 (6.2)
ranged from approximately 1 to 24 months, and 12
Homonymous hemianopia 3 (L) 1 (9.1) (75%) patients presented within 4 months of onset.
Extracranial TB was detected in five patients (31.5%)
L  left; R  right; VI  abducent nerve; III  oculomotor nerve.
in the form of miliary TB, lymphadenopathy, epididi-
morchitis and scalp cold abscesses. Miliary TB was
tein derivative [PPD] injected intradermally), CT scan defined as presence of miliary pattern on CXR or mul-
or MRI with contrast (the latter was introduced later in tiple organ involvement.
the country), search for M. tuberculosis in sputum or None of the patients had a past history of TB, but
aspirated material by direct Ziehl-Neelsen (Z-N) stain- two admitted to close contact with a family member
ing and light microscopy and by culture in Löwenstein- who had pulmonary TB (PTB) and shared the same
Jensen medium. residence. One patient had diabetes mellitus.
Material for histopathological diagnosis was ob-
tained from the brain in three patients who underwent Laboratory investigations
craniotomy before the diagnosis, lymph node resection The blood counts showed mild to moderate anemia
in two, testicular biopsy in one and a scalp abscess in- (hemoglobin level 4.5–9.4 g/dl) and normal white cell
cision in another one. count, except in one of the two patients with miliary
The patients received standard doses of anti-tuber- TB, who showed leucopenia of 1200/mm3 (Table 2).
culosis treatment. Four drugs, RMP, isoniazid (INH), The ESR was elevated (40–78 mm) in the first hour in
pyrazinamide (PZA) and streptomycin (SM) or eth- all patients. The tuberculin test was strongly positive;
ambutol (EMB) were given in the first 2 months, fol- the reaction was 15–20 mm diameter in 10 and ne-
lowed by RMP and INH for 16 months. The progress crotic in two. In all patients, the human immunodefi-
was regularly assessed in the out-patient neurology ciency virus (HIV) test was negative by the enzyme-
clinic by clinical and serial CT/MRI examinations. linked immunosorbent assay (ELISA) method.

Table 2 Demographic characteristics, pertinent laboratory tests, confirmatory histopathology and clearance of lesions with drug
treatment in 16 patients with intracranial tuberculoma

Tuberculin Brain
Age, Duration, HB WBC  ESR test lesions, Histo- Lesion
n years/sex months (g/dl) 103/l (1st h) (mm) n Extracranial TB pathology clearance
1 35/M 2 9.0 2900 40 Necrotic Single No Not done Complete
2 60/M 1 8.6 4300 66 18 Single No Not done Complete
3 19/F 4 8.0 6600 78 15 Single No Not done Complete
4 20/F 3 8.5 7200 60 20 Single No* Done Complete
5 45/F 2 6.8 4200 40 20 Single No Not done Complete
6 27/F 24 8.0 1200 72 12 Multiple Miliary TB Not done Died
7 38/M 2 8.0 5600 55 15 Single No Not done Complete
8 34/F 1 9.4 4600 70 Necrotic Multiple No Not done Complete
9 51/M 2 9.3 7200 60 20 Multiple No Done Complete
10 45/F 3 4.5 7200 70 20 Multiple Cervical LN Done Complete
11 40/F 6 9.0 6500 50 18 Multiple No* Done Complete
12 35/F 4 9.6 3800 66 16 Single No Not done Complete
13 17/F 5 4000 80 Necrotic Multiple Scalp abcesses Done Complete
14 40/M 4 7.7 4500 83 Not tested Multiple Miliary TB, epididimorchitis Done Incomplete
15 32/M 6 —† —† 85 Positive Single Axillary, cervical LN Done Complete
16 50/F 4 —† —† 67 Not tested Multiple No Not Done Incomplete

* Close contact with pulmonary tuberculosis case in the same residence.

† Initial data at presentation were missing.

HB  hemoglobin; WBC  while blood cell; ESR  erythrocyte sedimentation rate; TB  tuberculosis; M  male; F  female; LN  lymph nodes.

CT/MRI scan of the brain
On non-contrast CT scans the lesions were isodense
or slightly hyperdense rounded or irregular lobulated
mass that showed perifocal edema of variable exten-
sion. In eight (50%) of the cases the tuberculomas were
multiple. Contrast enhancement occurred in 14 cases
and was seen as homogeneous, or more typically as
ring enhancement. On MRI, the tuberculoma appeared
Figure 1 Case 14. Brain MRI showing an isodence lobulated
tuberculoma in the posterior parasagittal parietal region (A)
with marked gadolinium enhancement in T 1-weighted images
(B) and associated perilesional edema in coronal sections of the
T2-weighted sequence (C). MRI  magnetic resonance imaging.
Intracranial tuberculoma 93
isointense in T1 weighted images and hyperintense in
T2. In the majority of patients (n  14), the location
of the tuberculomas was supratentorial, evolving in
the hemispheres either unilaterally or bilaterally. Three
cases showed infratentorial lesions, two in the cere-
bellar hemisphere and one in the brain stem (Figures
1 and 2).
Bacteriology and histopathology
Biopsy material was obtained from the brain in three
cases and from cervical lymph nodes in two. Light mi-
croscopy revealed characteristic features of caseating
tuberculous granuloma. M. tuberculosis was isolated
from sputum obtained from the two patients with
miliary TB and from the scalp cold abscess.
Treatment and follow-up
The patients were given anti-tuberculosis treatment
as previously described. Dexamethazone was given to
relieve increased intracranial pressure in nine patients
with papilledema and extensive perilesional edema.
Follow-up of the tuberculomas by CT/MRI scan re-
vealed complete clearance of the lesions in 13 patients.
Partial clearance was observed in two patients with
multiple large intracranial lesions, one of whom had
miliary disease involving several organs, and the remain-
ing patient died as a result of advanced, extensively
disseminated disease before completing treatment.
Figure 2 Case 16. (A, B, C) MRI showing bilateral enhancing
cerebral tuberculomas associated with brain edema. (D) Com-
plete resolution of lesions and edema after anti-tuberculosis
treatment. MRI  magnetic resonance imaging.
94 The International Journal of Tuberculosis and Lung Disease
DISCUSSION
The clinical features of intracranial tuberculoma are
varied and non-specific, ranging in severity from sub-
tle to severe illness, partly depending on the time of
presentation. Fortunately, the introduction of recent
imaging facilities such as CT and MRI has enhanced
our diagnostic certainty and increased case detection.
Most of our patients presented with headache, epi-
lepsy, increased intracranial pressure and weakness of
extremities. The latter two features suggest delayed
presentation. In our series the diagnosis was definite
in seven cases where histopathological and/or bacte-
riological evidence of M. tuberculosis infection was
provided. In the remaining nine cases, the diagnosis
was considered probable based on typical imaging fea-
tures and resolution of lesions on anti-tuberculosis drug
treatment. About one third of the patients showed overt
extracranial TB manifestation. The presence of con-
comitant extracranial involvement can provide a valu-
able clue to the diagnosis of tuberculoma, especially if
the latter occurs at brain sites difficult to access.6,7 In
our series, associated pulmonary miliary TB, cervical
lymphadenopathy, epididimorchitis and cold abscesses
had suggested the tuberculous nature of the intracra-
nial lesions. Associated epididimorchitis and scalp in-
fection with tuberculoma are rare, and have been re-
ported previously.6,8 The tuberculin test was positive
in all patients, but the reaction tended to be stronger
in those with extracranial involvement. Nevertheless,
it is recognized that a positive tuberculin test is of lim-
ited diagnostic value in communities where TB is en-
demic, because of frequent mycobacterial exposure.9
The role of neuro-imaging by CT or MRI scan in
the diagnosis of tuberculoma is well-established, es-
pecially in high-prevalence regions. Most tuberculo-
mas develop in the supratentorial brain, and brain-
stem lesions are uncommon.10 Only one patient in
our series, who was investigated by MRI, showed a
brainstem tuberculoma. It is generally recognized that
MRI is superior to CT in visualizing the morphologi-
cal details of tuberculoma, and particularly the tiny
brain stem lesions. Despite the practical help that con-
ventional CT and MRI provide in resolving the differ-
ential diagnosis in cases of tuberculoma, they still lack
final specificity.4,5 Enhancing lesions such as gliomas,
metastatic tumors, abscesses, cysticercosis, mycotic
and other granulomas can mimic the radiological fea-
tures of tuberculoma and cause difficulties in differen-
tiation. However, further improvements in diagnostic
efficacy have been made possible by utilizing MR dif-
fusion weighted imaging,11 spectroscopy12 and mini-
mally invasive CT-guided biopsy.13
Polymerase chain reaction (PCR) on cerebrospinal
fluid (CSF) samples to detect DNA from mycobacteria
is a potentially useful and promising non-invasive tech-
nique for rapid diagnosis of tuberculoma even with-
out meningitis and with negative smear and culture.
Although the test has persistently proven high speci-
ficity (80–100%), a wider sensitivity range (30–100%)
has been shown.14–16 Moreover, laboratory contami-
nation and sampling errors can cause false-positive
results. Unfortunately neither PCR nor the advanced
imaging facilities are readily available in economically
under-privileged countries where the infection is most
prevalent. Lumbar puncture for CSF examination
was avoided in our series because of suspicion of in-
creased intracranial pressure, as clinically suggested
by the presence of papilledema (56.2%) and significant
brain edema in almost all cases.
The rate of resolution of the intracranial lesions on
anti-tuberculosis therapy has been reported anecdot-
ally in countries with high prevalence, and so far there
is no consensus regarding the optimal duration of treat-
ment. The few studies available from developing coun-
tries on the frequency of radiological clearance have
shown complete resolution of the intracranial lesions
in 80–100% of patients on short-course (6–12 months)
chemotherapy.17–20 A recent study from India, includ-
ing only histopathologically verified cases, revealed a
lower rate of 54% complete resolution by 24 months
of treatment.21 The authors assumed that because of
the failure of pathological verification, studies show-
ing higher frequencies might have included cases with
lesions other than tuberculomas.21
The outcome of treatment in our patients was re-
markably favorable, and in the majority (80%) the le-
sions had completely cleared within 18 months. Ex-
cept in those patients with advanced disseminated
disease, the progress of clinical improvement was
rapid, and symptomatic recovery preceded the radio-
logical clearance of lesions. We did not observe the
uncommon phenomena of paradoxical expansion
and de novo evolution of lesions that are reported to
occur during anti-tuberculosis therapy.22–24
In view of the favorable outcome of medical treat-
ment, especially among patients who presented early, we
also advocate early empirical trials of anti-tuberculosis
drugs for intracranial tuberculoma, particularly in areas
where the infection is endemic even after a presump-
tive diagnosis. Timely initiated medical therapy alone
has made this potentially fatal disease more often cur-
able and reduced the need for surgical intervention.20,21
References
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OBJECTIFS : Décrire les aspects cliniques, les signes radio-
logiques et les résultats du traitement par médicaments
antituberculeux dans 16 cas de tuberculome intracrânien.
S C H É M A : Ont été inclus dans l’étude tous les cas consécu-
tifs admis pour tuberculome au Centre National des Mala-
dies Neurologiques à Khartoum, Soudan. Le diagnostic a
reposé sur les aspects cliniques et ceux d’imagerie neurolo-
gique et sur la réponse au traitement antituberculeux. Dans
sept cas, on a disposé de l’examen histopathologique de pro-
duits venant du cerveau ou d’autres tissus extracrâniens.
R É S U L T A T S E T C O N C L U S I O N S : Les signes d’appel les
plus courants ont été les céphalées (100%), les convul-
sions généralisées (68,7%) et l’hémiparésie (56,2%). Au
OBJETIVOS : Describir la presentación clínica, los hal-
lazgos radiográficos y el desenlace del tratamiento anti-
tuberculoso de 16 casos de tuberculoma intracraneal.
M É T O D O : Se incluyeron en el estudio los casos consecu-
tivos de tuberculoma hospitalizados en el National Center
for Neurological Diseases en Jartún, Sudán. El diagnós-
tico se basó en las características clínicas, la neuroima-
ginología diagnóstica y la respuesta al tratamiento anti-
tuberculoso. En siete de los casos se contó con muestras
diagnósticas de tejido cerebral o extracraneal.
R E S U L T A D O S Y C O N C L U S I Ó N S : Las características clí-
nicas de presentación más frecuentes fueron cefalea
(100%), convulsiones generalizadas (68,7%) y hemipare-
View publication stats
Intracranial tuberculoma 95
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trolled clinical trial of short-course chemotherapy for tubercu-
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cranial tuberculoma. Zhonghua Jei He He Hu Xi Za Zhi 1996;
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Evolution of brain tuberculomas under standard anti-tuberculous
treatment. J Neurol Sci 1998; 156: 47–52.
21 Poonnoose S I, Rajshekhar V. Rate of resolution of histological ver-
ified intracranial tuberculoma. Neurosurgery 2003; 53: 873–879.
22 Afghani B, Lieberman J M. Paradoxical enlargement or devel-
opment of intracranial tuberculomas during therapy: case re-
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culosis. Lancet 2005; 5: 795–801.
RÉSUMÉ
tomodensitométrie (CT) et à l’imagerie par résonance mag-
nétique (IRM), on a observé des lésions uniques ou mul-
tiples avec renforcement intense du contraste et un œdème
périlésionnel. Dans la majorité des cas qui ont survécu
(13/15), les lésions se sont nettoyées complètement sous
traitement antituberculeux. Une résorption partielle de
la lésion a été en association avec un diagnostic tardif, la
présence de grandes lésions multiples et celle d’une mala-
die miliaire avancée. Nous plaidons en faveur d’un essai
empirique précoce de traitement antituberculeux pour
les tuberculomes intracrâniens, même après un diagnos-
tic de probabilité, particulièrement dans les régions où
l’infection est endémique.
RESUMEN
sia (56,2%). La tomografía computarizada (CT) y las
imágenes par resonancia magnética (IRM) pusieron en
evidencia lesiones únicas o múltiples con un realce in-
tenso con el medio de contraste y edema perilesional. Las
lesiones regresaron completamente con el tratamiento
antituberculoso en la mayoría de los sobrevivientes (13
de 15). Una regresión parcial de las lesiones se asoció con
presentación en etapa avanzada, lesiones grandes y múl-
tiples y enfermedad miliar avanzada. Se propone un trata-
miento antituberculoso empírico temprano para el tu-
berculoma intracraneal, incluso frente a la presunción
diagnóstica, en las zonas donde la infección es endémica.