An 18-year-old male presented with complaints of sub-acute onset, moderate to severe, occipitonuchal headache associated with vomiting and low grade fever 1 year back. He was initially evaluated and treated by a primary care physician. The treatment records were not available with the patient. With some symptomatic relief after initial 2 months of treatment, he discontinued medications without any medical advice or further follow-up. For another 9 months he continued to have recurrent off and on headache at irregular intervals which used to get relieved with over the counter medications. Over the last 6 months he had symptoms suggestive of progressive gait ataxia and right upper limb intentional tremors. For last 1 month he had resurgence of the symptoms in the form of severe holocranial headache, vomiting and fever. There was no history of seizures, loss of consciousness, any bulbar symptoms, diplopia, facial numbness or weakness. There was no significant past medical history. He was unmarried, rural dweller with agriculture as main vocation. There was no history of any high risk sexual behaviour. His mother took treatment for pulmonary tuberculosis for 9 months, 15 years back. Her exact medication records were not available.
On examination the general physical examination was unremarkable. He was conscious and well oriented to time place and person. All the cranial nerves including fundus were within normal limits. There was horizontal nystagmus in right eye on right lateral gaze with fast component towards the side of gaze. There was hypotonia on right side with grade power five in all limbs. Deep tendon reflexes were bilaterally grade two. Pendular right knee jerk was observed. Sensory examination was normal for touch, pain temperature, joint position, and vibration sense. Right sided cerebellar signs were present in the form of intentional tremors, dysdiadokokinesia, past pointing, and dysmetria. Gait was ataxic, wide based with tendency to sway on right side. Rest of the other systemic examination was normal.
Clinically, space occupying lesion in the right cerebellum-infective granuloma/benign or low grade malignancy was suspected. Routine hematological and biochemical investigations including hepatorenal functions were within normal limits. No abnormality was detected on chest roentgenograph. Enzyme-linked immuno sorbent assay for the HIV was negative. Induration of 16 mm in diameter was noted on a tuberculin skin test. The Magnetic resonance imaging of cranium revealed Intra axial T2 hyperintense and T1 hypointense parenchymal lesion in right cerebellum [Figure 1]. The gadolinium contrast revealed ring enhancement and there was restriction on diffusion weighted image [Figures 2a and 2b]. The Magnetic resonance spectroscopy study showed lactate and lipid peak [Figure 3]. In view of the radiological abnormalities, possibility of tubercular or pyogenic abscess was kept. Aerobic and anaerobic culture of pus drained from the burr hole was sterile. The microscopic examination of the pus smear demonstrated acid fast bacilli [Figure 4]. The pus culture using Lowenstein jensen media for mycobacteria was sterile after 7 weeks. Histopathology of abscess wall showed chronic inflammatory infiltrate without evidence of caseating granuloma or fungal elements. After drainage of the pus, anti-tubercular therapy was started which resulted in clinically significant resolution of the symptoms. He still continues to be on anti-tubercular therapy and is under regular clinical follow up.