Intracranial tuberculoma in Africa, with no available neuroimaging. Case report and review of the literature

The numerous extrapulmonary manifestations of tuberculosis have been well described. Intracranial localizations, including brain stem tuberculoma, are very rare. The authors report a case of brain tuberculoma in a patient with a history of primary pulmonary tuberculosis successfully treated more than twenty years earlier. The patient presented with signs of infection, although the fever disappeared temporarily after successive treatments for malaria (confirmed Plasmodium faiciparum), as well as neurological signs with left hemiparesis. Chest radiographs showed no signs of progressive pulmonary tuberculosis, and blood tests, cerebrospinal fluid testing, and HIV serology were all negative. Treatments for maxillary sinusitis, the malaria, bacterial meningitis, and cerebral abscess were equally ineffective. Brain stem tuberculoma was diagnosed only when the patient was transferred to a hospital equipped with neuroimaging equipment and was confirmed after histopathological examination of the intracranial lesion biopsies and the detection of mycobacterium DNA by polymerase chain reaction (PCR) in the cerebrospinal fluid. A review of 147 cases of intracranial tuberculoma reported in Africa between 1985 and 2001 points out the difficulties of both the differential diagnosis (tuberculoma or other intracranial space-occupying lesions) and treatment in African areas where neuroimaging is unavailable. Our patient's brainstem tuberculoma probably resulted from reactivation of latent tuberculosis.