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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 11  |  Issue : 2  |  Page : 211-213

A rare case of intramedullary tuberculosis with paraparesis


1 Department of Neurosurgery, IMS and SUM Hospital, Bhubaneswar, Odisha, India
2 Department of Pathology, IMS and SUM Hospital, Bhubaneswar, Odisha, India
3 Department of Neurology, IMS and SUM Hospital, Bhubaneswar, Odisha, India

Date of Submission12-Mar-2022
Date of Decision07-Apr-2022
Date of Acceptance13-Apr-2022
Date of Web Publication14-Jun-2022
Date of Print Publicaton14-Jun-2022

Correspondence Address:
Abhijit Acharya
Department of Neurosurgery, IMS and SUM Hospital, Bhubaneswar, Kalinga Nagar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_39_22

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  Abstract 


Intramedullary tuberculoma (IMT) is considered to be a rare form of spinal tuberculosis (TB). Overall, TB of the central nervous system accounts for approximately 1% of all cases of TB and 50% of these involve the spine. The clinical presentation of spinal intramedullary TB is similar to an intramedullary spinal cord tumor mass. The factors attributable could be malnutrition, poor socioeconomic conditions, and immunodeficiency syndromes. As per the reports, the incidence of primary intramedullary TB is 2 in 100,000 cases among patients with TB. We describe one such patient who presented with progressive asymmetrical paraparesis due to histologically confirmed intraspinal tuberculoma. Paraparesis in spinal IMT is considered to be rare. Hereby, we present the case of a 29-year-old female who presented with asymmetric onset paraparesis of 6 months with associated numbness and tingling began in the left foot 3 months which was ascending in nature. There was no history of stiffness, involuntary movements, flexor spasms, thinning, or fasciculations of muscles. There was a loss of sensation pain, touch, and temperature below L3 with normal reflexes. Power in both the lower limbs was 1/5 as per Medical Research Council (MRC) grading. She underwent a contrast magnetic resonance imaging spine which was suggestive of an intramedullary SOL at D12 vertebral level. The patient underwent surgical intervention with resection of the SOL. Histopathology was confirmed to be an IMT. She was started on Category 1 (antitubercular drugs) and further investigated for primary source, which was found to be negative. We want to emphasize that TB can involve any part of the body. It should be kept as a differential diagnosis of any chronic inflammatory lesion involving the bony skeleton, especially in endemic countries where combined surgical and medical treatment is usually sufficient to provide a cure.

Keywords: Intramedullary tuberculoma, paraparesis, spinal cord, surgical treatment


How to cite this article:
Acharya A, Panigrahi S, Choudhary RP, Puppala S, Dash A. A rare case of intramedullary tuberculosis with paraparesis. Int J Mycobacteriol 2022;11:211-3

How to cite this URL:
Acharya A, Panigrahi S, Choudhary RP, Puppala S, Dash A. A rare case of intramedullary tuberculosis with paraparesis. Int J Mycobacteriol [serial online] 2022 [cited 2022 Aug 11];11:211-3. Available from: https://www.ijmyco.org/text.asp?2022/11/2/211/347514




  Introduction Top


Tuberculosis (TB) of the central nervous system (CNS) is rare, with an incidence of 0.5%–2% in patients with systemic TB.[1],[2],[3] Pott's disease of the spine (tuberculous spondylitis) is the most common (60%), followed by arachnoiditis (20%), meningitis (12%), and intramedullary lesion (8%). The most common form of spinal intradural TB is meningitis. Intramedullary involvement is rare in TB and usually present in the form of radiculomyelitis, transverse myelitis, intraspinal granulomas, or thrombosis of the anterior spinal artery.[3] Spinal intramedullary TB (SIMT) has a similar presentation as compared to intramedullary spinal cord tumor. When diagnosed in time and managed appropriately, SIMT has a good prognosis.


  Case report Top


A 29-year-old female presented with asymmetric onset paraparesis of 6 months. Weakness began initially in the left foot 6 months before admission, followed by the right foot weakness began 2 months later slowly progressing to proximal muscles. Numbness and tingling began in the left foot 3 months ago and ascended proximally. There was no history of stiffness, involuntary movements, flexor spasms, thinning, or fasciculations of muscles. She was able to walk with support earlier; however, she had gradually progressive weakness, leading to walking with support followed by inability to stand with support and was bedridden and with difficulty in sitting and moving on the bed. She had urinary urgency and precipitancy for 2 months without bowel symptoms. There were no symptoms in the upper limbs, chest, or trunk. She denied a history of neck pain, back pain, and root pains. There was no history of significant loss of weight and appetite. She denied a history of systemic illness such as TB and diabetes mellitus. There was no history of exposure to toxins, alcohol intake, fever, or TB.

On examination, she was afebrile with normal vital signs. No hepatosplenomegaly, lymphadenopathy, or spinal deformity was clinically elicited. There was mild atrophy of the left leg and foot muscles; however, both were symmetrical. She has paraparesis (right: proximal 2/5 and distal 0/5; left: proximal 2/5 and distal 0/5). Sensations were impaired below L3. Muscle stretch reflexes were normal in the upper limb and sluggish in the lower limb. The plantar response was flexor on both sides. Cremasteric reflex was absent.

The hematological and biochemical investigations including Vitamin B12 level and tumor markers were normal. Chest X-rays were normal. Magnetic resonance imaging (MRI) of the spine revealed an intramedullary lesion with intense peripheral enhancement and perilesional edema at the D12-L1 level [Figure 1]. She underwent Eleventh thoracic(D11) to first Lumbar(L1) laminectomy.This was followed by posterior midline myelotomy and then total excision of intramedullary granuloma.This granuloma was sent to Histopathology that revealed features of tuberculoma [Figure 2]. She was started on antituberculous therapy and is on follow-up.
Figure 1: T2-weighted image of the axial section of the brain showing a hyperintense subgaleal collection present in the scalp which is in communication with the epidural collection

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Figure 2: Histopathology of the Intramedullary granuloma revealed features of tuberculoma

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  Discussion Top


Lesions from TB may be found in every organ, and CNS is one of the common sites of involvement in the extrapulmonary TB. Tubercular meningitis and cerebral tuberculoma are the most common manifestations of neurotuberculosis. Myelopathy or myeloradiculopathy is the less common presentation in primary intraspinal TB.

TB of the spine causes extramedullary compression and commonly presents with myelopathies.[4] Primary tubercular parenchymal involvement of the spinal cord is uncommon.[1],[4] Intramedullary TB is often associated with pulmonary TB but some cases may present with isolated extrapulmonary form.[5] The higher incidence involving the dorsolumbar area is explained based on the regional blood flow to the spinal cord.[6]

MRI is the preferred investigation to demonstrate the intramedullary lesions including tuberculomas.[7]

Surgical intervention is required in intramedullary tuberculomas for the confirmation of diagnosis and to reduce the granuloma burden.[8] As it is firm and well-circumscribed, it allows surgical removal without significant trauma to the cord. The results of surgical treatment together with antitubercular drugs are a preferred treatment of choice.

Acknowledgment

We acknowledge SOA University, Bhubaneswar, Odisha, for their help in doing this work.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rhoton EL, Ballinger WE Jr., Quisling R, Sypert GW. Intramedullary spinal tuberculoma. Neurosurgery 1988;22:733-6.  Back to cited text no. 1
    
2.
Nussbaum ES, Rockswold GL, Bergman TA, Erickson DL, Seljeskog EL. Spinal tuberculosis: A diagnostic and management challenge. J Neurosurg 1995;83:243-7.  Back to cited text no. 2
    
3.
Lin TH. Intramedullary tuberculoma of the spinal cord. J Neurosurg 1960;17:497-9.  Back to cited text no. 3
    
4.
Hanci M, Sarioglu AC, Uzan M, Işlak C, Kaynar MY, Oz B. Intramedullary tuberculous abscess: A case report. Spine (Phila Pa 1976) 1996;21:766-9.  Back to cited text no. 4
    
5.
Devi BI, Chandra S, Mongia S, Chandramouli BA, Sastry KV, Shankar SK. Spinal intramedullary tuberculoma and abscess: A rare cause of paraparesis. Neurol India 2002;50:494-6.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Lim YS, Kim SB, Kim MK, Lim YJ. Disseminated tuberculosis of central nervous system: Spinal intramedullary and intracranial tuberculomas. J Korean Neurosurg Soc 2013;54:61-4.  Back to cited text no. 6
    
7.
Gupta VK, Sharma BS, Khosla VK. Intramedullary tuberculoma: Report of two cases with MRI findings. Surg Neurol 1995;44:241-3.  Back to cited text no. 7
    
8.
Biniwale SN, Rajshekhar V. Tuberculous osteomyelitis of the bone flap following craniotomy for a glioma. Neurol India 2000;48:91-2.  Back to cited text no. 8
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