A 22-year-old female patient came with chief complaints of neck pain, left upper limb weakness and bilateral upper limb paresthesia since 2 months. Patient had insidious onset of symptoms which were gradually progressive in nature. There was no history of fever or weight loss or loss of appetite.
MRI revealed a central, well-defined, elongated intramedullary lesion causing spinal cord expansion extending from lower border of C4 to upper border of C7 vertebral levels.
The lesion showed a hypointense centre with peripheral hyperintensity on T2W images (Figure 1a, 2b), was hypointense with faint peripheral hyperintensity on T1W images (Figure 2a) and revealed a peripheral thick rim of enhancement on post-contrast study (Figure 3). There was no diffusion restriction within the lesion or in the perilesional cord oedema. No calcification or haemorrhage was seen on gradient images.
Extensive T2/STIR hyperintense cord oedema was seen surrounding the lesion, extending all the way from the cervico-medullary junction to mid T7 vertebral level (Figure 1b,1c).
Background: Intramedullary tuberculoma (IMT) is an extremely rare lesion that should be distinguished from other space-occupying spinal cord lesions like neoplasms. Although it is a treatable condition, delaying diagnosis leads to significant morbidity.
Clinical perspective: Clinical presentation depends on the level of spinal cord involvement. It usually has a gradually progressive course. The patient may present with systemic symptoms like malaise, low-grade fever and weight loss. However, these are not always present, as in our case. Other sites of tuberculous infection may be found in the body, such as the lungs, abdomen, genitourinary system, skeletal system etc. Isolated intraspinal intramedullary tuberculomas are a rare occurrence.
Imaging perspective: The clue to the diagnosis of intramedullary tuberculoma is the presence of central T2W hypointensity, which is rare in other intramedullary neoplasms such as ependymoma and astrocytoma. The presence of peripheral rim-like enhancement also is a feature of tuberculomas, as opposed to the patchy or heterogeneous central enhancement in other intramedullary neoplasms. The extensive long-segment perilesional oedema seen in this case also pointed towards an infective or inflammatory condition, rather than a primary tumour, which usually show minimal to mild perilesional oedema. Findings of meningitis or arachnoiditis may aid in the diagnosis but are not always present.
Outcome: Our patient was operated on as a possibility of intramedullary neoplasm was considered, and surgical decompression was warranted for symptomatic relief. Histopathology revealed granulomas with caseation with no evidence of cellular atypia, suggestive of tuberculous aetiology, thus confirming the diagnosis of an isolated intramedullary tuberculoma. The patient was thus started on anti-tuberculous therapy.
In general, early diagnosis with timely treatment is crucial in the management of IMTs. Radiologists play an important role in early diagnosis, particularly in such atypical presentations of tuberculosis. Most of these patients respond well to anti-tuberculous drug therapy with good functional recovery. However, timely surgical decompression in selected cases, provide an excellent long-term outcome.
Take-Home Message / Teaching Points: Tuberculomas should be considered in the differential diagnosis of intramedullary lesions irrespective of patient age or the presence of extraspinal focus of tuberculosis, in countries endemic to tuberculosis, particularly in the presence of certain imaging findings such as the presence of central T2W hypointensity, peripheral ring-like enhancement and disproportionate perilesional oedema.
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