A 79-year-old African American male patient with a past medical history of prostate cancer presented with progressive weakness, headache, and confusion. Brain MRI with gadolinium contrast showed a 41 × 33 × 41 mm left frontal lesion at the surface of the left lateral ventricle with vasogenic edema and midline shift (). A stereotactic biopsy of the lesion presented the possibility of a non-caseating granuloma. Metastatic prostate cancer was ruled out. The free and total prostate specific antigen (PSA) level was within the normal limit. The patient had immigrated from Liberia but denied any constitutional symptoms such as fever, cough, night sweats, or weight loss. Quantiferon gold test was positive but active pulmonary tuberculosis was ruled out with chest imaging. The basic metabolic panel was unremarkable; complete blood count showed lymphocytosis only. HIV antibodies were negative. Subsequently, we proceeded with a lumbar puncture. Histoplasma, blastomycosis, and HIV antibodies in cerebrospinal fluid were negative. Serum Cryptococcus antigen, Bartonella Hensale, and Bartonella Quintana IgM and IgG and rapid plasma reagin (RPR) tests were negative. Bone marrow acid-fast bacteria (AFB) stain and culture, C-ANCA, and P-ANCA were negative. 1, 25 OH, 25 Oh vitamin D3, and angiotensin-converting enzyme level were within normal limits. He underwent a left-sided frontal open brain biopsy, and pathology results were compatible with non-caseous granulomatous inflammation (). Fungus tissue culture, sputum, and blood cultures were negative. He was empirically started on anti-tuberculous treatment with Ethambutol, Isoniazid (INH), Rifampin, Pyrazinamide, Pyridoxine, and dexamethasone. We were unable to achieve significant clinical improvement two weeks after anti-tuberculous treatment. Considering the possible diagnosis of neurosarcoidosis, methylprednisolone 1 g daily treatment was initiated for three days and gradually tapered. Later on, after six weeks, the culture of the brain biopsy result came positive for tuberculosis. Anti-tuberculosis (TB) medications were re-initiated, to be continued for 18 months. After two months of treatment, the control MRI brain with gadolinium contrast showed near resolution of the midline shift and a decrease in the left frontal lobe and bilateral parietal lobes edema ().
A 65-year-old female visited the emergency department, complaining about headache, paraplegia, numbness of both legs, and urinary incontinence for one week. She had a history of kidney transplantation because of a stage 5 chronic kidney disease. She was also diagnosed with active pulmonary TB two weeks ago and started taking the combination of antituberculosis medication (isoniazid, ethambutol, rifabutin, and pyridoxine). Neurologic examination revealed only a trace or a flicker of movement on both lower extremities and impaired sensations below T10 level, while the motor and sensory functions of upper extremities were normal. The anal sphincter tone was decreased, and the deep tendon reflexes were absent on both lower limbs.\nThe spine magnetic resonance imaging (MRI) showed a round, well-defined, intramedullary-enhancing lesion (7×6×14mm in size) at T9-T10 levels with high signal change of spinal cord at T5-L1 levels (). Surgical resection was performed to decompress the spinal cord. There was a noted greyish, well-demarcated, firm mass that was radically removed. Consistent with tuberculosis, the histopathologic examination showed noncaseating, granulomatous inflammation. A few acid-fast bacilli were detected in granuloma (), and the neurologic deficit was not fully recovered right after the resection. After surgery, patient complains of persistent headache, so we took brain MRI in order to differentiate the brain lesion and it revealed multiple rim-enhancing nodular lesions which were suggestive of tuberculomas (). Anti-tuberculosis medications were persisted with rehabilitation program.