Cavernous sinus tuberculoma mimicking a neoplasm: Case report, literature review, and diagnostic and treatment suggestions for tuberculomas in rare locations
A 42-year-old immunocompetent female patient presented with a 6-month history of severe intermittent right hemicraneal headaches. Four months later she developed a right eye ptosis and ophtalmoplegy. She had benign medical and epidemiologic histories. A neurologic examination revealed gaze limitations in all directions, ptosis of the right eye and right hemifacial hypoesthesia, with no signs of meningeal irritation. The general examination, routine hematologic examination, and chest radiography were normal with no history of fever or respiratory tract infections. Orbital computed tomographic scans and magnetic resonance imaging (MRI) were normal. Brain MRI revealed a right CS tumor []. Erythrosedimentation, HIV serology, VDRL, C3, C4, ANA, ANCA, thyroid profile, and PCR for Epstein–Barr virus and TB all yielded negative results. Cerebrospinal fluid (CSF) testing was normal.\nThe patient was empirically treated with steroids suspecting a granulomatous disease with partial clinical improvement; however, she did not take the medications regularly and missed physician follow-up evaluations. Five months later she was readmitted with a clinical relapse and a new cerebral MRI revealed marked tumoral progression with adjacent right mesial temporal involvement [Figure –].\nWith no definitive diagnosis and tumoral progression, the patient was referred to our Neurosurgery Department and a surgical excisional procedure was recommended.\nWe considered it an inconclusive case and with the suspicion of a brain neoplasm, under general anesthesia, a right craneo-orbito-zygomatic with extended middle fossa approach was performed. The extradural anterior clinoidectomy and the CS and middle fossa peeling, allowed to identify both dural layers (dura propia and dura periostica). The inner layer of the lateral wall of the CS was not infiltrated by the tumor. The basal temporal and CS dura propia with an infiltrative tumoral mass, invading the mesial temporal lobe, was resected. The tumor had a firm, white appearance []. Subtotal tumor resection was achieved as the intraoperative pathologic impression was of an inflammatory disease. The CS was not opened. Dural closure was achieved with fascia lata.\nMicroscopy revealed a caseous necrotic centre surrounded by a granulomatous reaction that included Langhans giant cells, epithelioid cells, and lymphocytes. In addition, there was abundant fibrosis [Figure and ]. Immunological test were performed and definitive pathologic findings consisted of a tuberculoma, although Ziehl Neelsen and PAS stains did not demonstrate acid-fast bacilli and bacteriologic cultures were negative.\nAntituberculous treatment was immediately begun with a four drug (rifampin, isoniazid, ethambutol, and pyrazinamide) 2-month regimen followed by a two drug (rifampin and isoniazid) regimen for 10 months, and dexamethasone for the first 8 weeks.\nThe postoperative course was uneventful with no surgical morbidity and clinical improvement in the weeks thereafter. The 1-year postoperative follow-up MRI showed complete regression of the lesion [Figure and ] and complete resolution of the symptoms.