A 1-year-7-month-old infant presented with shortness of breath since 1 week before admitted to hospital. The patient had a cough for the past 1 month. Intermittent fever history was found for the last 6 months. There were noticeable lumps in the neck that slowly grows over the past 8 months from the size of a marble to 5 x 3 cm in size, conglomerated and well-bordered. No history of seizure, projectile vomiting, TB contact, nor family history of malignancy. History of full-term vaginal delivery assisted by a midwife, with normal birth weight and complete immunization. There was weakness in both legs and right hand for the past 4 months and a nonenhanced head CT from a previous hospital revealed multiple masses in the pons, right basal ganglia and left thalamus; bilateral temporoparietooccipital vasogenic edema with bilateral coronary suture diastasis (sign of increased intracranial pressure) [Figure 1].
Laboratory findings showed lower hemoglobin level (6.4 gr/dl), higher white blood count (22.3 x 103/mm), lower albumin (2.7 gr/dl), and lower natrium index (127 mmol/L), while other whole blood cell test and other blood biochemical indexes were within normal ranges. The anteroposterior chest radiograph revealed mass density in the left lung field [Figure 2]. Then chest CT imaging was recommended for further evaluation. In the nonenhanced chest CT, a large pulmonary mass was found at the inferior lobe of the left lung with multiple calcified lymphadenopathies and signs of parenchymal consolidation. According to these manifestations, the authors suspected the mass was giant tuberculoma accompanied by mediastinal lymphadenopathies and bacterial pneumonia [Figure 3]. Cervical ultrasound showed multiple calcified lymphadenopathies in both cervical regions [Figure 4]. Brain MRI with contrast showed multiple lesions in the midbrain, right occipital lobe, and right caudate nucleus suggesting tuberculoma, and focal leptomeningitis in the bilateral occipital region [Figure 5].
The following day, Mantoux test was performed with negative induration, but microscopic test from gastric aspiration showed a positive acid-fast bacillus (AFB) smear proving an active pulmonary TB. The patient then started the initial regimens of anti-TB drugs with isoniazid, rifampicin, ethambutol, and pyrazinamide. An excisional lymph nodes biopsy from the cervical region was then performed to confirm the diagnosis. Histopathological review of the lumps concluded a chronic granulomatous lymphadenitis and supported a TB infection [Figure 6]. However, several days after the biopsy procedure, the patient's condition worsened followed by desaturation, bradycardia, and finally passed away.