A rare case of intramedullary tuberculoma: Complete resolution after medical treatment and role of magnetic resonance imaging in diagnosis and follow-up
A 23-year-old male, a software engineer by profession, presented with complaints of weakness of both lower limbs of 5 days duration, which initially started in left lower limb and subsequently involved the right lower limb. He also complained of loss of dexterity involving both upper limbs since 2 days. Along with this complaint, he also has a band-like feeling in the upper abdomen, urinary hesitancy, and a feeling of incomplete voiding of urine. On examination, his higher mental functions and cranial nerves were normal. All his reflexes were brisk and there was ill-sustained clonus on the right side. His upper limb power proximally was 5, while distally it was 4.His lower limb power was 3 and it followed a pyramidal distribution of weakness. He had sensory impairment below T7 corresponding to vertebral level D5 and altered sensation below C6. General physical examination and other system examinations were normal. A provisional diagnosis of cervical myelopathy was made and patient was investigated. His complete blood count, renal profile, liver function tests, human immunodeficiency virus (HIV), Venereal Disease Research Laboratory test, and hepatitis B surface antigen were negative. His chest X-ray showed right apical TB. Erythrocyte sedimentation rate was high and Mantoux was reactive. MRI whole cord revealed an iso- to hypointense lesion at D5 level and a swollen cord on T1-weighted imaging (T1WI). The lesion was hypointense on T2-weighted imaging (T2WI), with gross edema appearing hyperintense, extending up to the cervical and lower dorsal level. Contrast-enhanced MRI showed a ring-enhancing lesion at D5 with sharp margins. The oval-shaped lesion measured 1.44 cm × 0.91 cm. Cerebrospinal fluid (CSF) analysis showed increased cells with lymphocyte predominance and elevated protein. CSF polymerase chain reaction for mycobacterium TB was positive. A diagnosis of IMT and pulmonary TB was made and patient was started on antituberculous treatment (ATT) with steroids. His upper limb weakness could be attributed to the surrounding inflammatory edema which had extended till cervical and lower dorsal level. Over a period of 2 weeks, the patient improved very well and was able to walk without support. His upper limb weakness improved. Over a period of 3 months, his band-like feeling at upper dorsal level gradually improved and his lower limb power fully improved except for mild hesitancy while passing urine.\nMRI was repeated at 2nd and 6th months after starting ATT. Steroids were given for duration of 2 months. His second MRI showed significant decrease in the size of the lesion and his third MRI showed almost total disappearance of the lesion except for an insignificant edema at D5 level.