|Year : 2015 | Volume
| Issue : 2 | Page : 123-125
Spinal intramedullary tuberculoma: A rare cause of paraparesis
Bhautik V Tilva1, Karkal Ravishankar Naik1, Aralikatte Onkarappa Saroja1, Raviraj S Ghorpade2
1 Department of Neurology, KLE University's Jawaharlal Nehru Medical College, KLES' Dr. Prabhakar Kore Hospital and MRC, Belgaum, Karnataka, India
2 Department of Neurosurgery, KLE University's Jawaharlal Nehru Medical College, KLES' Dr. Prabhakar Kore Hospital and MRC, Belgaum, Karnataka, India
|Date of Web Publication||14-May-2015|
Bhautik V Tilva
Department of Neurology, KLE University's Jawaharlal Nehru Medical College, Nehru Nagar, Belgaum - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Spinal intramedullary tuberculoma is a rare cause of paraparesis. Clinical presentation is often nondistinctive in the absence of systemic tuberculosis. Magnetic resonance imaging reveals intramedullary granuloma with relatively distinct pattern with peripheral gadolinium enhancement resembling "target sign." Histolopathological evaluation is essential to differentiate it from other intramedullary lesions to offer curative treatment augmented by surgical excision. Early surgical intervention combined with anti-tubercular drugs yields good prognosis.
Keywords: Magnetic resonance imaging, paraparesis, spinal cord, tuberculoma
|How to cite this article:|
Tilva BV, Naik KR, Saroja AO, Ghorpade RS. Spinal intramedullary tuberculoma: A rare cause of paraparesis. J Sci Soc 2015;42:123-5
| Introduction|| |
Nervous system involvement with meningitis and tuberculoma are a common presentation of extrapulmonary tuberculosis. Tuberculomas occur most frequently in the intracranial compartment whereas the occurrence of isolated intramedullary tuberculoma of the spinal cord is rare.  The first documented case of intramedullary spinal cord tuberculoma was described by Abercrombie in 1830. The incidence of primary intramedullary tuberculosis is reported as 2 in 100,000 cases among all patients with tuberculosis.  We describe one such patient who presented with progressive asymmetrical paraparesis due to histologically confirmed intraspinal tuberculoma.
| Case report|| |
A 55-year-old man presented with asymmetric onset paraparesis of 5 months. Weakness began initially in left foot 4 months before admission and in right foot weakness began 3 months later slowly progressing to proximal muscles. Numbness and tingling began in left foot 3 months ago and ascended proximally. There was no history of stiffness, involuntary movements, flexor spasms, thinning or fasciculations of muscles. He had urinary urgency and precipitancy since 2 months without bowel symptoms. He had no symptoms in upper limbs, chest or trunk. He denied history of neck pain, back pain and root pains. He gave a history of significant loss of weight, appetite and intermittent dark colored stools for the last 5 months. He denied history of systemic illness like tuberculosis, diabetes mellitus. There was no history of exposure to toxins, alcohol intake, fever or tuberculosis.
He was afebrile with normal vital signs. There was no hepatosplenomegaly, lymphadenopathy or spinal deformity. There was mild atrophy of left leg and foot muscles. He had asymmetric paraparesis (right: Proximal 4+/5, distal 4/5; left: Proximal 4/5, distal 3/5). Sensations were impaired below L3. Muscle stretch reflexes were normal in upper limb and sluggish in lower limb. Plantar response was extensor on the right side and flexor on left. Cremasteric reflex was absent.
The hematological and biochemical investigations including Vitamin B 12 level and tumor markers were normal. Upper and lower gastrointestinal endoscopy and chest X-ray were normal. Magnetic resonance imaging (MRI) of the spine revealed intramedullary lesion with intense peripheral enhancement and perilesional edema at D12-L1 level [Figure 1]. He underwent D11 to L1 decompressive laminectomy with posterior midline myelotomy and total excision of intramadullary granuloma that revealed features of tuberculoma. He was initiated on antituberculous therapy (ATT), which he continued for 1-year. At 18 months after the surgery, he has minimal weakness in lower limbs with normal sphincter functions.
|Figure 1: Sagittal magnetic resonance images of the thoracolumbar spine. (a) T2-weighted image shows intramedullary peripherally hypointense lesion with central hyperintensity and peripheral edema at D12-L1 level ("target sign"). (b) T1-weighted image a er gadolinium shows intense|
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| Discussion|| |
Lesions from tuberculosis may be found in every conceivable body part, and central nervous system (CNS) is one of the common sites of involvement in the extrapulmonary tuberculosis. Tubercular meningitis and cerebral tuberculoma are the commonest manifestation of neurotuberculosis. Primary clinical presentation with myelopathy or myeloradiculopathy is less common.
Tuberculosis of the spine causes extramedullary compression leading to myelopathies is common.  Primary tubercular parenchymal involvement of spinal cord is uncommon. , Dastur reviewed 74 paraplegia due to tuberculosis without evidence of Pott's disease and discovered that extradural granulomas occurred in 64%, arachnoidal lesions without dural involvement in 20%, subdural/extramedullary lesions in 8% and intrameduallary lesions in 8%.  Involvement of spinal cord compared to that of the brain occurs in the ratio of 1:42. , Intramedullary tuberculomas are rarely reported in Western literature with prevalence of 2 out of 100,000 cases of tuberculosis.  Intramedullary tuberculosis is often associated with pulmonary tuberculosis, but some cases may present with isolated extrapulmonary form.  More than one site in the cord may be affected. The higher incidence involving the dorsolumbar area is explained on the basis of the regional blood flow to the spinal cord.  Differential diagnosis of intramedullary space-occupying lesions comprises of tuberculoma, primary and metastatic spinal tumors, and other chronic granulomatous disease such as sarcoidosis, Brucellosis More Details, histiocytosis, etc.  The lesion may increase in size while the patient is on ATT.
Magnetic resonance imaging is the preferred investigation to demonstrate the intramedullary lesions including tuberculomas.  The MRI findings in cases of spinal intramedullary tuberculoma vary during the different stages of tuberculoma. In the early stage, it is characterized by severe infective reactions, poor formation of the capsule with edema around the lesion. During this phase, T1-weighted and T2-weighted images show equal signal intensity with contrast enhancement. Later as the peripheral edema reduces, T1-weighted images shows isointensity whereas T2-weighted sequences reveal iso/hypo-intensity with peripheral enhancement and central hypointensity. With the development of caseation, T2-weighted images show enhancing ring lesion and sometimes the "target sign." The caseous substance forms the target center, whereas the peripheral infective granulation tissues form the high signal rim. The "target sign" is considered a useful indicator to differentiate spinal tuberculoma from other intramedullary lesions. However, target sign can also be seen in granulmatous and neoplastic disorders of the CNS. 
Surgical intervention is required in intramedullary tuberculomas to confirm the diagnosis and to reduce the granuloma burden.  As it is firm and well circumscribed, it allows surgical removal without significant trauma to the cord. The results of surgical treatment together with anti-tubercular drugs have been excellent as was observed in our patient.
| Conclusion|| |
Spinal intramedullary tuberculoma is a rare cause of paraparesis. Specific MRI findings augmented by the histological confirmation of the diagnosis are vital to the diagnosis. Early surgical intervention combined with ATT yields good prognosis.
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