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 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.