Brain Tuberculoma in a Non-Endemic Area
A 24 year-old man who had immigrated from Ethiopia six years prior presented to our Emergency Department with intermittent left leg shaking for two days. His left leg felt tired and he was reluctant to stand on it. He was previously healthy and had no history of fever, chills, night sweats, or weight loss. He was well appearing with no abnormal findings on physical and neurological examination. A computed tomography (CT) scan showed right frontoparietal edema. A contrast-enhanced scan was performed, revealing an associated frontoparietal enhancing mass. magnetic resonance imaging (MRI) of the brain demonstrated a 2.6×1.6 cm mass with surrounding edema (). CT of chest, abdomen, and pelvis revealed periceliac and peiraortic lymphadenopathy, and questionable but no definitive pulmonary nodules. Having received the Bacillus Calmette-Guérin vaccine, his tuberculin sensitivity test was positive. He was started on levetiracetam for treatment of simple partial seizures, and dexamethasone for treatment of vasogenic edema. He underwent right parietal craniotomy with intraoperative monitoring for resection of the lesion and tissue diagnosis. The underlying dura was soft and uninvolved. Opening the dura revealed a superficial mass with well defined margins that easily peeled away from the underlying parenchyma (). Pathological examination demonstrated necrotizing granulomas with peripheral palisading epithelioid histiocytes, giant cells, and acid fast bacilli, consistent with cerebral tuberculoma (). Blood cultures and HIV testing were negative. Following surgery, he had no neurological deficits and had no further seizure activity. He was rapidly tapered from steroids and continued on levetiracetam for an additional month. He completed a six-month regimen of isoniazid, rifampin, ethambutol, and pyrizinamide, and was doing well without neurological sequelae five months after completion of therapy.