Spinal intramedullary tuberculomas (SIMT) are rare. They are usually secondary to hematogenous dissemination. It is unusual for SIMT to present predominantly as chronic backache to the rheumatologist.
A 22-year-old woman presented with a history of insidious-onset, progressive, dull, low backache of 8-month duration. It was worse at night and poorly responsive to nonsteroidal antiinflammatory drugs. Radiographs of the thoracolumbar spine and pelvis were unrevealing. She had developed a mild left lower limb weakness for the past month. There was no history of fever or respiratory complaints. Neurological examination revealed a left extensor plantar response with grade 3/5 power in the left lower limb with patchy sensory loss. Magnetic resonance imaging (MRI) of the lumbosacral region revealed an intramedullary lesion of heterogeneous signal intensity on T2-weighted images at the level of conus medullaris with cord expansion and edema (Figure 1). The lesion displayed significant peripheral rim enhancement on the “T1W” postcontrast sequence (Figure 2). Computerized tomography of the thorax revealed fibronodular lesions, bronchiectatic changes, and infiltrates in bilateral lung fields with mediastinal lymphadenopathy, suggestive of tuberculosis. Cerebrospinal fluid PCR for Mycobacterium tuberculosis was positive. Serum anticysticercal and human immunodeficiency virus antibodies were negative. She started treatment with rifampicin, isoniazid, ethambutol, pyrazinamide, and dexamethasone. Backache subsided in 7–8 days and motor weakness resolved in 3 weeks. Dexamethasone was tapered and stopped at 6 weeks. MRI at 6 months showed complete resolution. Antitubercular therapy was continued for 12 months.
SIMT occur rarely, with an incidence of 2 per 100,000 patients of tuberculosis and are usually secondary to hematogenous dissemination. To our knowledge, fewer than 200 cases have been reported to date1,2. SIMT presenting predominantly as chronic backache to the rheumatologist is most unusual. Mainstay of therapy remains medical, with select cases requiring surgery3.