Intramedullary tuberculoma of the spinal cord: a series of 10 cases

doi:10.1016/S0303-8467(01)00196-2

Clinical Neurology and Neurosurgery

Volume 104, Issue 4, September 2002, Pages 279-284

https://doi.org/10.1016/S0303-8467(01)00196-2 Get rights and content

Abstract

Objective: Involvement of vertebral column is common in tuberculosis but intramedullary tuberculomas are rare. We report a series of ten cases of intramedullary tuberculomas, which, to the best of our knowledge, is the largest series of biopsy proven intramedullary tuberculomas in English literature. Methods: During a period of 16 years (1985–2000), ten cases of intramedullary tuberculomas were diagnosed in our department. Of these, eight cases were histologically proven intramedullary tuberculomas. The clinical profile, radiological data and histological slides were reviewed. Results: Age ranged from 18 to 45 years (mean 29.7 years) and there was slight male preponderance (six men, four women). Duration of symptom varied from 3 to 20 months (mean 11.5 months). All of them presented with motor weakness and sensory impairment. Most common site of involvement was dorsal cord followed by cervical, cervicodorsal and dorsolumbar regions. Three patients had associated involvement of lungs, cervical lymphnodes, and brain, and one patient had past history of tuberculous meningitis. Two patients were treated conservatively but surgical excision was done in eight cases followed by medical treatment. Conclusion: Radiologically, intramedullary tuberculomas should be differentiated from other space occupying lesions (SOL) to avoid unnecessary surgery especially in those patients with tuberculosis of the other organs. The incidence of intramedullary tuberculomas is likely to increase with a rise in the incidence of AIDS.

Introduction

Intramedullary spinal tuberculosis is a rare disease entity, which was first described by Abercrombie in 1828 [1] and since then, about 170 cases have been reported in the literature [2], [3], [4], [5], [6], [7], [8], [9], mostly in the form of case reports. Tuberculous involvement of central nervous system is not uncommon in India [10], [11], [12], however, intramedullary tuberculomas are relatively rare [9], [13], [14], [15], [16]. Although it is a treatable condition delay in diagnosis leads to significant morbidity.

We report a series of ten cases of intramedullary tuberculomas, which to the best of our knowledge, is the largest series of biopsy proven intramedullary tuberculomas in the English literature.

Section snippets

Materials and methods

All cases of intramedullary tuberculomas diagnosed in our department, were reviewed retrospectively. During a period of 16 years (from 1985 to 2000), ten cases of intamedullary tuberculomas were found. Records of the patients were retrieved. Clinical, radiological and pathological features were reviewed along with final outcome.

Five patients had CT myelography and three of them also had magnetic resonance imaging (MRI). The remaining five patients had MRI with gadolinium enhancement. Eight

Results

Age ranged from 18 to 45 years (mean 29.7 years) and there was slight male preponderance (M:F 1.5: 1) (Table 1). Duration of symptoms at presentation varied from 3 to 20 months (mean 11.5 months). All of them had motor weakness and sensory impairment except one patient. The classical dissociated sensory impairment was observed in three patients only. Half of them presented with urinary symptoms. One patient with cervical cord disease also had respiratory involvement.

Dorsal cord was involved in

Treatment and follow up

Two patients who had concurrent intracranial tuberculoma and cervical tuberculous lymphadenitis were managed conservatively and showed progressive improvement of their neurological symptoms. In eight patients, the diagnosis was established on histology. Preoperative diagnosis of tuberculosis was suspected in only four cases whereas, in others the possibility of intramedullary tumours were considered. Through laminectomy, excisions of lesions were done. At surgery spinal cord was found to be

Pathological examination

Material was submitted for pathological examination in eight cases. Microscopic examination shows necrotising granulomatous reaction in four cases (50%). The central areas of necrosis were surrounded by epithelioid cells, lymphocytes and Langhan's type giant cells. In four cases granulomas were non-caseating (Fig. 6). Stain for mycobacterium revealed acid fast bacilli in one case only. Special stains for fungus were negative.

Discussion

In the modern era of effective antitubercular regimens, central nervous system tuberculosis is a rare entity in the developed countries but is increasing, because of increasing incidence of AIDS [17]. Intracranial tuberculomas are still a common cause of space occupying lesion (SOL) in India [18] and pose a great health hazard.

Spinal tuberculosis most commonly present as tuberculous spondylitis [19] and arachnoiditis [20], [21] but isolated intramedullary tuberculomas without the involvement of

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Citation Excerpt :
Results of combined surgery and medical treatment are excellent. However, in cases of intramedullary lesion with associated tuberculosis in endemic areas like India or in cases where radiology is highly suggestive of intramedullary tuberculoma the medical treatment should be the first choice.4 Surgery indicated in those cases of tuberculoma in which there is neurological deficit, presence of paravertebral abscess, resistance to ATT and further there is possibility of spinal instability.9
Involvement of vertebral column is common in tuberculosis(TB) but intramedullary tuberculomas are rare. Spinal intramedullary tuberculoma are extremely rare, seen in only 2 of 100,000 cases of TB and 2 of 1000 cases of CNS TB^. Intramedullary tuberculomas normally respond well to conventional antituberculous medications, requiring surgery only occasionally. MRI is optimal diagnostic modality in intramedullary tuberculoma as it can show specific findings. This report describes a case of Intramedullary Tuberculoma of the Spinal Cord with clinical features and specific MRI findings with review of litreture.
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A total of 7 cases of peripheral nerve tuberculomas were reported in the literature, including the current case. The mean age was 21.4 years with no sex predilection. The ulnar nerve was involved in all cases. The most common clinical manifestations were hand weakness, atrophy, ulnar clawing, and hypoesthesia. The classic histopathologic features of caseous necrosis, epithelioid granulomas, and Langhans giant cells were seen in all cases, while staining for acid fast bacilli was positive in only one case. All patients underwent nerve exploration and lesion resection, and were given antitubercular treatment lasting between 3 and 18 months. Treatment resulted in complete recovery in 43% of cases and partial improvement of neurologic deficits in 57%.
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Intramedullary tuberculoma of the spinal cord: a series of 10 cases

Abstract

Introduction

Section snippets

Materials and methods

Results

Treatment and follow up

Pathological examination

Discussion

Int. J. Infect. Dis.

Clin. Imaging

Surg. Neurol.

Radiol. Clin. North Am.

Intramedullary tuberculomas of the spinal cord: case report and review

Rev. Infect. Dis.

Intramedullary spinal tuberculomas during treatment of tuberculous meningitis

Clin. Neurol. Neurosurg.

Intramedullary tuberculoma of the spinal cord: case report and review of the literature

J. Neurosurg.

intramedullary spinal tuberculoma presenting as a conus tumor: a case report and review of the literature

Eur. Spine J.

Intramedullary spinal tuberculoma: a case report

Spine

Intramedullary cervical tuberculoma

Spine

Diagnosis and neurosurgical treatment of tuberculous disease of the central nervous system

Neurosurg. Rev.