An 11-year-old male child presented with a history of drooping of both the eyelids for 5 days with associated headache and ataxia for 2 days. He had no history of fever, convulsion, or loss of vision. There was a history of contact with a case of TB in the neighborhood. Clinical examination revealed bilateral symmetrical ptosis [Figure 1], but the movement of both the eyeballs was normal in all the directions with normal pupillary size and reaction bilaterally. Other cranial nerves were essentially normal. Dysdiadochokinesia and ataxia were noted on the right side. No weakness was found in any of the limbs. Deep tendon jerks were bilaterally normal with a normal plantar response.
Investigations revealed normal blood counts and raised erythrocyte sedimentation rate. Mantoux test was negative and chest radiograph was normal. Magnetic resonance imaging (MRI) of the brain revealed single ring-like enhancing lesion in the dorsal part of the midbrain with significant perifocal edema in adjacent parts of the brainstem, right cerebellar peduncle, adjacent thalamocortical tract, and periventricular region [Figure 2]. MRS at the site of the lesion showed increased lipid peak, decreased N-acetylaspartate (NAA) peak with increased choline/creatinine ratio, suggestive of tuberculoma [Figure 3].
He was started on four drugs antitubercular treatment (ATT) (isoniazid [10 mg/kg/day], rifampicin [10 mg/kg/day], ethambutol [25 mg/kg/day], and pyrazinamide [35 mg/kg/day] - all thrice a week) along with intravenous dexamethasone (0.6 mg/kg/day in 4 divided doses). Later, dexamethasone was switched over to oral prednisolone at 1 mg/kg/day which was tapered after 6 weeks. Ataxia and headache responded within 2 days of starting the treatment, whereas drooping of eyelids improved gradually after 4 weeks of treatment. No worsening of symptoms was noted. ATT was continued for 12 months (2 months intensive phase with four drugs, followed by 10 months continuation phase with isoniazid and rifampicin) and the child is doing well without any symptom at 12 and 18 months follow-up.