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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 122-124

Brain tuberculoma in a Colombian indigenous child


1 Department of Pathology, Meakins-Christie Laboratories, McGill University Health Centre, Montreal, Canada; Department of Pathology and Microbiology, National University of Colombia School of Medicine, Bogotá, Colombia
2 Department of Surgery, Neurosurgery Unit, National University of Colombia School of Medicine, Bogotá, Colombia

Date of Submission21-Jan-2021
Date of Acceptance03-Sep-2021
Date of Web Publication5-Apr-2022

Correspondence Address:
Dr. Leonardo F Jurado
Department of Pathology, McGill University, Duff Medical Building, 3775 University Street, Room B4, Montreal H3A2B4, Quebec, Canada

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/RID.RID_9_22

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  Abstract 


Despite global efforts to eradicate tuberculosis (TB), 10 million new cases are reported each year. Indigenous communities are at greater risk of developing TB. We report a 7-year-old indigenous boy who presented with neurological symptoms. An intracranial neoplasm was suspected based on imaging findings and he underwent neurosurgical resection. The final diagnosis was intracranial tuberculoma. Anti-TB therapy was administered and the patient recovered completely.

Keywords: Central nervous system, Colombia, indigenous communities, tuberculosis


How to cite this article:
Jurado LF, Hernández-Gómez V, Arias J. Brain tuberculoma in a Colombian indigenous child. Radiol Infect Dis 2021;8:122-4

How to cite this URL:
Jurado LF, Hernández-Gómez V, Arias J. Brain tuberculoma in a Colombian indigenous child. Radiol Infect Dis [serial online] 2021 [cited 2022 Aug 20];8:122-4. Available from: http://www.ridiseases.org/text.asp?2021/8/3/122/342626




  Introduction Top


Ten million new cases of TB are reported every year worldwide. According to estimates, children under 15 years of age account for 11% of all cases.[1] In Colombia, this age group accounts for 4% of reported TB cases each year; only 2% of all cases each year occur in children under age 5 years.[2] However, indigenous communities, who represent 3.5% of the Colombian population, have a higher risk of developing TB because of factors such as genetic predisposition, lifestyle, limited access to health care, and poverty.[3],[4]


  Case Report Top


A 7-year-old boy from the Nukak-Makuk Colombian indigenous community presented to the emergency department with a 10 day history of headache, vomiting, and generalized convulsive seizures. Neither fever nor tuberculosis (TB) history was reported. The patient appeared emaciated. His height and weight were 115 cm and 20 kg, respectively. Body mass index was 15.1. Laboratory testing showed the following: red blood cell count, 6.5 million cells/μl; hemoglobin, 12.2 g/dL; hematocrit, 36.8%; white blood cell count, 10,200 cells/μl; platelet count, 142,000/μl; erythrocyte sedimentation rate, 18 mm/h; and C-reactive protein, 10 mg/L. Other blood parameters were normal.

According to the patient's father, the patient had not received any vaccinations and no Bacillus Calmette–Guérin vaccination scar was visible on the left deltoid. Brain imaging studies showed a right frontal lesion suggestive of a tumor [Figure 1]; therefore, transcranial surgical resection of the affected tissue was performed. H and E and Ziehl–Neelsen staining of the surgical specimen revealed inflammatory granulomatous disease and acid-fast bacilli [Figure 2]. The patient was treated with rifampicin, isoniazid, pyrazinamide, and ethambutol for 2 months followed by 4 months of rifampicin and isoniazid, which resulted in complete recovery with no neurological sequelae. His nutritional status improved as well.
Figure 1: Brain magnetic resonance imaging. Sagittal contrast-enhanced T1-weighted imaging shows a hypointense expansive lesion (arrow) in the medial frontal gyrus with partially defined borders and peripheral enhancement

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Figure 2: Hematoxylin and eosin stain, ×10. The cerebral parenchyma is affected by the chronic granulomatous disease with necrosis (arrow), multinucleated giant cells, and lymphocytic infiltrates

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  Discussion Top


TB of the central nervous system (CNS) is uncommon but frequently fatal. It accounts for 5% to 10% of cases of extrapulmonary TB and 1% of TB-related deaths and is more frequent among children and HIV-infected individuals.[5],[6] In the patient reported here, his indigenous ancestry increased his risk of developing the disease.[3]

Given the infrequent occurrence and nonspecific symptoms of CNS TB, prompt diagnosis is challenging.[5] Children with this condition usually present with fever, seizures, nausea, and vomiting; headache is uncommon.[5],[6] Interestingly, our patient presented with headache but no fever.

TB can involve the brain or spinal cord and is broadly classified into meningeal and parenchymal forms [Table 1]. Any combination of the patterns can occur. Meningitis is most frequent, followed by tuberculoma, brain abscess, and encephalitis.[7]
Table 1: The spectrum of central nervous system tuberculosis

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As observed in our patient, the anatomical effects of CNS TB can be easily appreciated on magnetic resonance imaging, which is considered the best modality to image patients with suspected CNS TB.[8],[9] The radiological differential diagnosis of tuberculoma includes fungal granuloma, pyogenic abscess, lymphoma, metastasis, and late-stage neurocysticercosis (NCC); less commonly, as in our patient, glioma may be confused with a tuberculoma.[8],[9],[10]

Large tuberculomas may resemble neoplastic lesions on magnetic resonance imaging, as they predominantly exhibit high signal intensity on T2-weighted imaging, mixed intensity on T1-weighted imaging, and heterogeneous enhancement on contrasted imaging.[8],[9],[10] NCC generally appears as a ring-enhancing lesion and should be considered in the differential in countries such as Colombia where both infections are endemic.[8] TB lesions are usually located at the parenchymal gray–white junction, while NCC is usually located in the subarachnoid space of the brain sulci. TB lesions are commonly larger than 2 cm, while NCC is usually smaller. Extension of perilesional edema is typically greater in tuberculomas.[8],[9]

Differentiation of tuberculomas from brain metastases may also be challenging, as both can be multiple. Nevertheless, metastatic lesions are usually hyperintense on T2-weighted imaging and associated with a greater extension of perilesional edema; tuberculomas are typically hypointense on T2-weighted imaging.[8],[9],[10] [Table 2] summarizes the magnetic resonance imaging characteristics of brain tuberculomas.
Table 2: Magnetic resonance imaging characteristics of brain tuberculomas

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Brain tuberculomas are thought to result from the growth of tubercles that seed the brain parenchyma during hematogenous dissemination of the primary infection but do not rupture into the subarachnoid space.[5] As in our patient, a single tubercle may grow without showing manifestations of meningitis. Patients may also present with multiple tuberculomas and/or with signs of meningitis.[5],[7] Regardless, the mainstay of brain tuberculoma management is surgical excision combined with antitubercular therapy.[7]

Histologic examination of lesions usually shows a granulomatous reaction along with epithelioid cells, giant cells, lymphocytes, and caseous necrosis.[5] These findings led to the diagnosis of intracranial tuberculoma in our patient. Adequate treatment resulted in total recovery.

Approximately 400 indigenous communities inhabit Latin America and the Caribbean. They account for more than 10% of the total population in this region. In Colombia, approximately 4% of the people are indigenous.[11] The TB situation among the indigenous communities of Latin America is concerning. For example, in Paraguay, the incidence of TB is as high as 392 per 100,000.[12] The prevalence of TB among the indigenous people of Columbia is 2646 per 100,000 on the Atlantic coast and 172 per 100,000 in the Amazon rain forest.[3] Both social and sanitation interventions are needed among the indigenous population to reduce the incidence and impact of preventable diseases such as TB.[3],[11]

Today, more than a century after the discovery of Mycobacterium tuberculosis, factors such as poverty, cultural and social inequality, human immunodeficiency virus infection, and the emergence of multidrug-resistant TB remain formidable obstacles to TB control despite widespread use of directly observed therapy.[1],[4] More effective strategies for control and eventual elimination of TB are needed, especially in indigenous communities. Surveillance, information systems, and health-care access should be strengthened at the country level, and national and international plans to curb poverty and social inequality should be implemented.[1],[3],[4]

Acknowledgment

We thank Liwen Bianji (Edanz) (www.liwenbianji.cn/) for editing the English text of a draft of this manuscript.

Ethic statement

Not applicable.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
WHO. Global Tuberculosis Report 2019. Geneva: World Health Organization; 2020. Available from: https://www.who.int/publications/i/item/9789240013131. [Last accessed on 2022 Feb 07].  Back to cited text no. 1
    
2.
National Institute of Health. Event report. Tuberculosis 2017. Bogotá D.C: National Institute of Health; 2017. Available from: https://www.ins.gov.co/buscadoreventos/Informesdeevento/Tuberculosis%202017.pdf. [Last accessed 2022 Feb 07].  Back to cited text no. 2
    
3.
Jurado LF, Murcia MI, Arias J, Sánchez L. Pott's disease in a Colombian indigenous man. Biomedica 2015;35:454-61.  Back to cited text no. 3
    
4.
Jurado LF, Palacios DM. Tuberculosis: A Risk Factor Approach. London. IntechOpen; 2018. Available from: https://www.intechopen.com/chapters/59122.  Back to cited text no. 4
    
5.
Rock RB, Olin M, Baker CA, Molitor TW, Peterson PK. Central nervous system tuberculosis: Pathogenesis and clinical aspects. Clin Microbiol Rev 2008;21:243-61.  Back to cited text no. 5
    
6.
Perez-Velez CM, Marais BJ. Tuberculosis in children. N Engl J Med 2012;367:348-61.  Back to cited text no. 6
    
7.
Kumar R, Pandey CK, Bose N, Sahay S. Tuberculous brain abscess: Clinical presentation, pathophysiology and treatment (in children). Childs Nerv Syst 2002;18:118-23.  Back to cited text no. 7
    
8.
Khatri GD, Krishnan V, Antil N, Saigal G. Magnetic resonance imaging spectrum of intracranial tubercular lesions: One disease, many faces. Pol J Radiol 2018;83:e524-35.  Back to cited text no. 8
    
9.
Trivedi R, Saksena S, Gupta RK. Magnetic resonance imaging in central nervous system tuberculosis. Indian J Radiol Imaging 2009;19:256-65.  Back to cited text no. 9
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10.
Raut AA, Naphade PS, Ramakantan R. Imaging spectrum of extrathoracic tuberculosis. Radiol Clin North Am 2016;54:475-501.  Back to cited text no. 10
    
11.
Montenegro RA, Stephens C. Indigenous health in Latin America and the Caribbean. Lancet 2006;367:1859-69.  Back to cited text no. 11
    
12.
Hurtado AM, Hill KR, Rosenblatt W, Bender J, Scharmen T. Longitudinal study of tuberculosis outcomes among immunologically naive aché natives of paraguay. Am J Phys Anthropol 2003;121:134-50.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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