a 24-year - old male was admitted to our hospital with a 1 week history of progressive headache and fever .
his previous medical history was clear . on the neurologic examination , his mental status was normal without focal neurological deficits .
lumbar cerebrospinal fluid ( csf ) analysis showed pleocytosis , increased total protein level ( 167 mg / dl ) and decreased glucose ( 32 mg / dl ) .
tubercle bacillus was detected in the csf and the adenosine deaminase ( ada ) level was elevated ( 12
brain mri revealed small , multiple high signal intensity lesions on the diffusion weighted image .
his chest x - ray showed diffuse ill - defined patches and nodules with increased density in both apical lungs .
tuberculosis meningitis and pulmonary tuberculosis were suspected and antituberculous treatment with rifampicin , isoniazid , ethambutol and pyrazinamide was started .
nine days after the antituberculous treatment , his general condition and headache had improved significantly . however , four weeks after antituberculous treatment , he developed acute sensory disturbance below t10 dermatome as well as urination disturbances .
spinal mri showed a long segmentally located soft tissue mass mimicking a meningioma in the intradural , extramedullary space of the posterior spinal canal from t2 to t6 with severe cord compression and displacement ( fig .
1 ) . surgical decompression and a biopsy were performed . during the operation , a t3 ,
the dura was thickened and the cord was infiltrated with an adhesive mass . the dura was opened and closed in the normal manner after removing the mass under microscope guidance . grossly , the mass was very soft with a dark green color .
the cultures were negative for mycobacterium tuberculosis , and the stains for fungi and acid - fast micro organisms were negative .
mri of the thoracic and lumbar areas showed lumbosacral tuberculosis spondylitis with multiple abscesses ( fig .
anti - tuberculous medication was continued for 18 months . at the one year follow - up
spinal involvement in tuberculosis is classified into four categories : potts spine , nonosseous spinal tuberculoma , tuberculous arachnoiditis and tuberculous meningitis .
intradural spinal tuberculomas are estimated to be composed of only 2% to 5% of central nervous system tuberculomas.1,3 - 5 ) compton and dorsch8 ) reported 11 cases of intratudral extramedullary tuberculoma in 1984 .
since then , there have been 19 more cases reported in the english literature.1,3,5 - 9 ) all cases , except for 4 initially presented with tubculous meningitis .
most case reviews involved the thoracic spine.1,3,5 - 10 ) the diagnostic method is generally histopathology , even though afb cultures from the granulomas were positive in only one of the reported cases.7 ) a myelogram can be helpful but mri is the diagnostic procedure of choice .
interestingly , most intradural extramedullary tuberculoma cases were detected after antibuberculous therapy had been initiated , which is known as paradoxical response.2,4,7 ) tuberculoma can occur at any time but most reported cases showed a paradoxical response during the early course of chemotherapy , which ranged from 3 weeks to 1 year.2,4,7 ) the mechanism for the paradoxical response is unclear .
however , is is believed to be the result of an interaction between the host 's immune response and the direct effects of mycobacterial products.2,3,7,10 ) this condition has been recognized more frequently .
narita et al.10 ) reported paradoxical worsening in up to 36% of patients with tuberculosis and aids after antiretroviral therapy .
therefore , mental or focal neurological changes during the follow - up must be checked in patients with tubeculous meningitis.2,10 ) the prognosis for neurological improvement is good with a prompt surgical excison and appropriate antituberculous medication.3,4,6 ) although intramedullary tuberculoma can be treated with medication alone , an intradural extramedullary tuberculoma is essential for surgery when compression of spinal cord occurs .
en plaque meningioma can present with thoracic spinal cord and nerve root compression.1 ) the case presented herein was initially diagnosed with en plaque meningioma based on the radiological findings .
the differential diagnosis between tuberculous patchy meningitis and meningioma in the form of plaque is difficult without obtaining a biopsy specimen . in conclusion
, intradural extramedullary tuberculoma can occur in tuberculous meningitis patients as a paradoxical response to antituberculous chemotherapy .
although quite rare , intradural extramedullary tuberculomas should be considered in a differential diagnosis of an en plaque meningioma of the spinal cord .
 a 24-year - old man with tuberculosis meningitis developed acute paraplegia and sensory disturbances 5 weeks after receiving conventional antituberculous therapy . magnetic resonance imaging revealed an intradural extramedullary long segmental mass mimicking en plaque meningioma at the t2-t6 vertebrae levels . 
 prompt surgical decompression was performed . 
 a histology examination of the mass revealed a tuberculoma . 
 after surgery , the patient showed improved motor power and a normal bladder function . 
 intradural extramedullary tuberculoma of the spinal cord is rare complication of tuberculosis meningitis , which can occur as a response to conventional antituberculous therapy . 
CASE REPORT
DISCUSSION