An 11-year-old, Indonesian girl has been complaining persistent headache in the past 3 years. The headache was getting worse.
The patient had a history of surgical excision of craniopharyngioma [Figure 1] 8 years ago, and placement of VP shunt flat bottom type, medium pressure, on the right Kocher point due to postoperative hydrocephalus. After the craniopharyngioma excision surgery, the patient never had radiotherapy due to her young age.
From the anamnesis, the patient did not have TB symptoms such as prolonged cough, unexplained fever, weight loss, and night sweats. The patient had no history of contact with family, friends, or surrounding people with TB disease. The patient had no history of previous routine antibiotics treatment.
On examination, the patient had a stable vital sign with normothermia. She was fully conscious with GCS E4M6V5. There were no meningeal sign nor nuchal rigidity. Other neurological examinations were normal. The patient was immunocompetent and well-nourished. There was no sign of systemic TB nor meningoencephalitis. Routine laboratory tests and chest X-ray were all normal.
Brain magnetic resonance imaging (MRI) [Figure 2] revealed a 4 x 2.3 x 2.1 cm mass surrounding the ventricular drain which was attached in the anterior horn of the right lateral ventricle to the right frontal cortex. The mass was isointense in T1 and hypointense in T2. After administration of gadolinium, the mass was highly heterogenous contrast enhancement. There was perifocal edema around the tumor.
On dynamic susceptibility contrast (DSC) MRI perfusion, the relative cerebral blood volume appeared to be elevated, leading to a malignant process. On MR Spectroscopy (MRS) [Figure 3], the Choline/Creatine and Choline/NAA ratio appeared to be elevated with Choline map also increased.
There was no sign of hydrocephalus nor residual of craniopharyngioma. No sign of meningoencephalitis was seen.
From brain MRI examination suggested a process of seeding metastases surrounding the ventricular drain in the area of the anterior horn of the right lateral ventricle to the right frontal cortex.
From the preoperative anamnesis, physical examination, and imaging, the mass suggested a metastatic process with no suspicion of tuberculoma. Therefore, we did not give trial antibiotics or TB treatment before surgery.
Surgery was done to reduce mass effect symptoms, as well as to obtain tissue to establish the diagnosis. The initial goal of surgery was gross total resection. A right frontotemporal craniotomy was performed. The existing chamber and peritoneal drain of VP shunt were disconnected and removed.
The lesion appeared to be surrounding the ventricular drain. The lesion was solid, firm, calcified, and adheres tightly to the ventricular drain. The lesion was very hard and cannot be easily separated by electrocautery and suction. Therefore, careful piecemeal debulking of the tumor was carried out using scissors, until the tumor was completely removed and healthy parenchymal tissue was seen.
Histopathology examination [Figure 4] revealed a large fibrotic area containing many granulomas, consisting of epithelial cells surrounded by lymphocytes. An area of necrosis was seen in the center of the granuloma with foci of calcification. Langhans giant cells were also seen at the periphery of the granuloma. There was no sign of malignancy. Histopathological findings were consistent with tuberculoma.
Unfortunately, the samples of operation were only examined for histopathology. There were no samples sent to the microbiology department for culture examination.
There was no complication after surgery. The patient was discharged on postoperative day 3 in good condition. Five months after surgery, the patient is still routinely checked in to the outpatient clinic. There are no complaints or neurological deficits. Currently, the patient is receiving treatment for extrapulmonary TB.