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Tuberculomas, both intracranial tuberculomas and tuberculomas of the nerve canal, are one of the forms of manifestation of central nervous tuberculosis. Who is at risk of developing brain tuberculoma? What are the symptoms and treatment of this extrapulmonary form of tuberculosis?

Tuberculomas of the brain and nerve canalis one of the extrapulmonary forms of tuberculosis. Bothintracranial tuberculomasandnerve canal tuberculomasare really rare - the involvement of the central nervous system by tuberculosis is the most severe form of tuberculosis - most often it occurs in children from 4 months of age up to 4 years and adults with impaired immunity. Children who are not vaccinated with BCG at birth are particularly vulnerable. There are geographic differences. In countries with high incidence of tuberculosis, the disease affects young children and usually occurs 3-6 months after primary infection. In low-incidence countries, on the other hand, it is mainly adults who suffer from the disease, and this is usually the result of reactivation of a latent focus formed in the past. In the risk group there are:

  • patients with AIDS
  • drug addicts and alcoholics
  • people with weakened immunity dependent on T lymphocytes
  • homeless
  • malnourished and emaciated
  • people over 65
  • subjected to long-term immunosuppression
  • treated with corticosteroids
  • people with diabetes
  • lymphoma patients

How are tuberculomas formed?

The causative agent of tuberculosis is Mycobacterium tuberculosis ( Mycobacterium tuberculosis ) - Gram positive rod-shaped bacterium. When a primary infection occurs, the mycobacteria travel through the bloodstream to the brain and spinal cord. There, lumps, i.e. small foci of inflammation, form under the cortex or on the meninges. It can take variously long periods of time - from several weeks to many years - before meningitis develops.

Rich's bonfire is created - cheese lumps. When its contents are broken into the subarachnoid space, inflammation develops in response to the antigens of mycobacterium tuberculosis. It is most strongly expressed at the base of the brain, where a thick, gelatinous exudate accumulates. As a result of inflammation, cranial nerves are damaged and the circulation of the cerebrospinal fluid is disturbedleading to hydrocephalus, involvement of blood vessels resulting in cerebral infarctions.

Central nervous system involvement may also be an element of miliary tuberculosis. Only in a few cases is it the result of contagion spreading through continuity.

When the nodules enlarge but do not break into the subarachnoid space, tuberculomas are formed. They can form in a variety of brain structures. These are cheesy necrotic masses surrounded by fibrous tissue, specific granulation tissue and a chronic inflammatory infiltrate. When it breaks down inside, brain abscesses form. Complication of abscesses may be cold paravertebral or extra-scleral abscesses. Numerous tuberculomas and brain abscesses typically occur in AIDS patients.

Tuberculomas of the brain and spinal canal: symptoms

Intracranial tuberculomas are manifested by the symptoms of an intracranial expansive process:

  • headaches
  • nausea
  • vomiting
  • sleepiness
  • disturbance of consciousness
  • focal symptoms
  • convulsions
  • optic disc swelling

May coexist with meningitis.

Tuberculomas of the spinal canal are most often located in the middle of the thoracic segment. Patients complain about:

  • back pain
  • paresthesias
  • electrocution
  • bladder dysfunction
  • muscle atrophy

Tuberculosis: research

When suspecting tuberculoma, one should look for the manifestation of tuberculosis in other organs as well. The basis is chest X-ray examination, which in half of adults and most children shows changes characteristic of active or past tuberculosis. High-resolution computed tomography can be useful in the case of miliary lesions that cannot be shown by X-ray. Tuberculin test is currently of little diagnostic value, usually positive, but negative does not exclude tuberculosis.

Examination of the cerebrospinal fluid is essential. At first glance, the liquid is clear, opalescent. The general examination shows: high level of mononuclear cells, especially lymphocytes, slightly increased level of protein (up to 5g / L), decreased glucose concentration (more than twice as compared to serum). It should be remembered that the correct glucose concentration does not exclude tuberculous inflammation. Except for HIV positive patients, the simultaneous normal concentration of protein, glucose, and normal white blood cell count in the cerebrospinal fluid argue against the diagnosis of tuberculosis. Even after the initiation of treatment, the changes persist for 10-14 daysin the cerebrospinal fluid.

Cerebrospinal fluid is also cultured, but we have to wait several weeks for the results. Molecular techniques (PCR, ELISA), which significantly accelerate diagnostics, are helpful. We perform imaging examinations of the central nervous system (magnetic resonance imaging and computed tomography). In the case of the presence of lesions suggesting tuberculomas in the imaging tests, verification by biopsy is necessary, because they do not differ in the image from neoplastic lesions. In tuberculomas without concomitant meningitis, the cerebrospinal fluid is normal or only slightly increases in protein levels.

Tuberculosis: treatment

Pharmacotherapy for tuberculosis is based on regimens consisting of several antituberculosis drugs. Administration of drugs is necessary because without drugs the mortality rate is 100%. In addition, the disease continues to progress for several days after the initiation of treatment. Treatment begins with intensive therapy - isoniazid (INH), Rifampicin (RMP), Pyrazinamide and Streptomycin (SM) are administered for two months. INH, RIF and SM penetrate well into the cerebrospinal fluid.

Patients should be closely monitored because Herxheimer reaction may occur after the first dose of drugs - rapid disintegration of mycobacteria causes an increase in symptoms.

If the clinical condition improves, two drugs are used in the continuation phase for the next months: RIF and INH. In the case of tuberculomas, the treatment of INH and RIF should be extended to two years, because we may be dealing with a paradoxical reaction, when even after several months of antituberculosis treatment, tuberculomas become enlarged.

Some cases require neurosurgical intervention.

It should also be remembered that anti-tuberculosis drugs have numerous side effects. For this reason, patients must be kept under constant supervision. INH can cause neuropathy, so it is given together with pyridoxine for prophylaxis. Due to the ototoxicity of MS, monthly auditing is recommended. INH, RIF and Pyrazinamide are hepatotoxic, therefore liver enzymes should be monitored.

Important

Tuberculomas: prognosis and complications

The severity of consciousness disorders is important in prognosis. 50-70% mortality is observed among unconscious patients. Young children and the elderly are less likely to recover. Possible complications:

  • memory loss
  • dementia
  • hydrocephalus
  • epilepsy
  • blindness
  • deafness
  • electrocutioncranial nerves
  • intellectual impairment in children

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Category:

Neurology