A 16-year-old boy, with no medical history, presented to the emergency department in March 2014 complaining of severe headache of 1-month duration. The headache was progressive in nature and associated with recent development of vomiting and blurred vision. There was no history of fever, weight loss, recent travel, or contact with sick patients.
The neurological examination showed massive papilledema with vertical nystagmus and diplopia.
The laboratory test results were normal including complete blood count, urea, electrolytes, and liver function tests. Provisional clinical diagnosis of intracranial space-occupying lesion was made, and MRI of the brain with intravenous gadolinium was performed for further evaluation. The MRI [Figure 1] showed an enhancing midline mass at the pineal region causing obstructive supratentorial hydrocephalus.
Additional laboratory tests for AFP and BHCG showed normal results. Pineal gland germinoma was suspected. MRI of the whole spine was performed and returned to be normal. The patient was initially managed by third ventriculostomy and external ventricular drain placement. CT examination after removal of the ventricular drain is shown in Figure 2.
The patient underwent excision biopsy with frozen section histopathology demonstrating granuloma consistent with TB with encephalitis without any malignant cells. The final pathology report confirmed the diagnosis and showed few small non-necrotizing granulomas, perivascular lymphocytic infiltrates, and reactive microglia without evidence of malignancy. ZN stain for acid bacilli was negative. However, considering the low sensitivity of the stain, TB was the leading diagnosis while sarcoidosis was the less likely second differential consideration. Sarcoidosis was excluded as CT chest was normal and angiotensin-converting enzyme level was negative. The decision was made to start the patient on anti-TB medications for 18 months and dexamethasone for 6 weeks. MRI was performed 2 months after the start of treatment [Figure 3] and showed significant decrease in the size of the enhancing lesion.
The patient was followed up in the clinic for 2 years, and all the symptoms have resolved except for persistent binocular diplopia. MRI examination after 1 year of the treatment [Figure 4] was performed and showed further decrease in the size of the granuloma.
In December 2016, the patient presented again with new onset of gradual left side hypoesthesia, weakness, and unsteady gait. He did not report fever or night sweats. Neurological examination revealed normal fundoscopy without papilledema. The 3rd cranial nerve palsy was present on the right side with diagonal diplopia in all direction including primary gaze. Motor examination showed mild left-sided drift with no hyperreflexia.
Sensory examination showed left-sided numbness with impaired left upper and lower limb proprioception. The right-sided dysdiadochokinesia was also noted.
MRI examination [Figure 5] was done and showed two new enhancing lesions at the right cerebral peduncle and right thalamus. CSF analysis was normal. PPD test was negative. The patient was diagnosed as paradoxical reaction and recommenced on anti-TB medications.
The treatment was effective with resolution of the patient's symptoms. MRI examination performed in March 2017 [Figure 6] and December 2019 [Figure 7] showed resolution of the tuberculoma with residual gliosis. The patient is currently asymptomatic and following in the clinic.