A 19-year-old male came to the hospital presented with back pain and weakness of both lower limbs of three months duration. It initially started in the left lower limb and subsequently involved the right lower limb. The patient also complained of urine hesitancy and a feeling of incomplete voiding of urine, but normal defecation. He came from primary health facility with acid-fast bacilli (AFB) smear-positive sputum. He was on anti-tubercular treatment for last two months with non-reactive HIV status, but there was no significant past medical history such as cough, night sweat, or decreased body weight. He denied any recent exposure from people who had tuberculosis.
On examination, his mental functions and cranial nerve were normal. All of his reflexes are brisk and had a Babinsky sign for both of the lower limbs. Both of the upper limbs power were 5/5, whereas both of the lower limbs were 2/5. He had sensory impairment below T6 corresponding to vertebrae level and altered sensation with hypoesthesia. Laboratory findings revealed negative sputum examination for tuberculosis. Plain chest X-Ray, thoracolumbal, and lateral radiographs revealed normal finding (Fig. 1). Magnetic Resonance Imaging (MRI) on T1-weighted image exhibited hypointense portion, which appeared to surround the intermediate intensity lesion. The hypointense part represented the inflammatory reaction that occured around the lesion, whereas the isointensity in the middle reflected the presence of necrosis. Axial T1- weighted image showed an intradural hypointensity at T6 level (Fig. 5). T2-weighted image also showed low signal intensity at the vertebral level of thoracal VI, VII, and VIII. The hypointense portion reflected necrosis and also hypocellularity with increased macrophages and gliosis. The pathological layers were indistinguishable on T2-weighted image (Fig. 2). The patient suspected with intramedullary mass spinal tumour. With the above imaging characteristics of intramedullary lesion, differential diagnosis of tuberculous granuloma, ependymoma and glioma were suggested.
Surgical resection was performed through posterior approach from T6 to T8 Level. Midline durotomy was perfomed and showed a thick mass intramedullary tumour at the vertebral level of thoracal VI, VII, and VIII (Fig. 3). The patient underwent posterior decompression of spinal cord and vertebral laminectomy with open biopsy. The tuberculoma was a brown greyish, multilobulated, irregular, but well-circumscribed mass. Excisional biopsy resulted as granulomatous chronic inflammation process, which was seen by the formation of epitheloid histiocytes (multinucleated langerhans type giant cells), with peripheral lymphocytes and plasma cells, and a central area of caseous necrosis. These pictures below were suggestive for tuberculoma of the spinal cord (Fig. 4).
The patient's lower limbs power gradually improved throughout one month after the surgery. Clinically, there was an improvement in neurological deficits and bladder dysfunction, but he still had mild hesitancy while passing urine. The patient was able to ambulate independently and resume productive activities.