A 48-year-old African American female presented with a one-month history of headaches and nausea. Her only significant past medical history was diabetes. Her social history was negative for such risk factors as a high-risk profession in the healthcare field, recent incarceration, known contact with persons diagnosed with active tuberculosis or recent travel to areas in which tuberculosis is endemic. Her physical exam was unremarkable, and she had no focal neurological deficits. She was afebrile and hemodynamically stable. She presented to an outside facility where she had a computerized tomography (CT) scan of her head performed, which showed a posterior fossa mass with moderate hydrocephalus. This was followed by a magnetic resonance imaging (MRI) of the brain with and without contrast, which revealed a large right cerebellar ring-enhancing mass (Figures -). The primary concern at that time was that this mass could possibly be a primary brain glioma like a high-grade astrocytoma or a medulloblastoma. The patient was transferred to another hospital for neurosurgical evaluation and excision of the mass. She underwent an exploratory posterior fossa craniectomy, cerebellar exploration and decompression, but no mass was identified at that time. Due to persistent headaches, she then had a repeat exploration of posterior fossa 15 days later, and identification and excision of the cerebellar mass occurred. Histopathology from the procedure revealed necrotizing granulomas (Figure ), and stains specific for acid fast bacilli and fungus were both negative. Subsequently, the brain tissue grew Mycobacterium tuberculosis. The patient reported no prior knowledge of having tuberculosis, nor did she endorse exposure to patients with active tuberculosis. She previously had purified protein derivative (PPD) tests for employment, which had been negative. She was not immunocompromised and had recently been tested negative for human immunodeficiency virus (HIV) six months prior.
A 5-year-old boy presented with fever for 12 days, progressive motor weakness in lower limbs for 9 days, and retention of urine and constipation for 6 days. The patient was treated elsewhere for fever for three days. However, on the fourth day of the illness, the child developed progressive symmetrical lower limb weakness causing difficulty in standing, sitting, and turning from side to side. Over the next three days, he developed retention of urine and constipation, hence was referred to our hospital for further management.\nThere was no history of headache, vomiting, altered sensorium, cranial nerve or sensory deficit, recent immunization, and head or spine trauma. The patient had no tuberculosis (TB) in the past nor TB contact.\nAt admission, his pulse rate was 88/min, respiratory rate was 32/min, and blood pressure was 90/60 mm of Hg. Bacillus Calmette Guerine vaccine scar was seen. Spine palpation revealed no tenderness or deformity. His weight (16kg) and height (106cm) both were between the 10th and 25th centiles for his age and sex. His higher mental functions, cranial nerves, and sensory examination were normal, and papilledema was absent. Tone, power, and reflexes of both upper limbs were normal. Both lower limbs had hypotonia, power grade 2/5, and exaggerated (3+) deep tendon reflexes. Abdominal and cremasteric reflexes were absent and plantar reflexes were extensor bilaterally. Meningeal signs were absent. The patient had mild firm hepatomegaly (2cm) and a palpable distended urinary bladder. Respiratory and cardiovascular system examination was normal.\nHis initial investigations showed iron deficiency anemia and elevated Erythrocyte sedimentation rate (25 mm at 1h), a negative Mantoux test, normal chest radiograph, and gastric aspirate negative for acid-fast bacilli. Enzyme-linked immunosorbent assay was negative for human immunodeficiency virus infection. MRI of dorsal spine (P + C) showed a well-defined oval T2 hypointense ring-enhancing lesion (4.5 × 2.5 mm) in the thoracic cord at D4-D5 level, with mild perilesional edema from D3 to D5 level suggestive of IMT []. MRI of brain revealed few tiny T2/fluid attenuation inversion recovery (FLAIR) hyperintense enhancing foci in left frontal white matter and subependymal region of the left ventricle. Minimal focal subcortical white matter edema was observed in right frontal lobe suggestive of tuberculoma [].\nThe patient was started on ATT regime containing two months of Isoniazid (H), Rifampicin (R), pyrazinamide (Z) and Ethambutol (E) followed by 7 months of Isoniazid (H), Rifampicin (R) and Ethambutol (E) therapy (2HRZE +7HRE) with steroids for four weeks. Parenteral dexamethasone was given for two days followed by oral prednisolone for a total of four weeks. He showed clinical improvement in three days and had complete clinical recovery by nine days. Meanwhile, family screening for TB detected sputum positive for pulmonary TB in father. His father was enrolled and started on standard ATT, the younger sibling was started on isoniazid prophylaxis as per Revised National Tuberculosis Control Program guidelines. On follow-up, the patient was found to be compliant with ATT and clinically well without adverse effects.