Tuberculous granuloma of the spheno-clival region.

Sir, The clivus is one of the common sites for diverse pathological lesions. 1 Tuberculosis commonly involves the craniovertebral junction causing atlanto-axial dislocation. However, primary skull base tuberculoma is extremely rare. A case of primary spheno-clival tuberculoma without involvement of the craniovertebral junction is reported and the management is discussed. A 24-year-old, non-immunocompromised lady presented with history of progressive diplopia and inward deviation of both eyes for one month. Cranial nerve examination revealed paresis of both lateral recti. The rest of the neurological and systemic examination revealed no abnormality. Her hematological and laboratory examination revealed no abnormality. Chest X-ray was normal. CT scan revealed evidence of an isodense, minimally enhancing, destructive and expansive clival lesion (Figure 1). T1-weighted MRI images showed an isointense lesion involving primarily the clivus and sphenoid sinus and extending anteriorly into the nasopharynx. The lesion enhanced on Gadolinium. There was a central zone of necrosis. The craniovertebral junction was normal (Figure 2). The patient underwent a trans-ethmoidal decompression of the lesion. The lesion was firm in the periphery and was vascular. However, the central part of the tumor was cheesy and avascular. Histopathological examination of the specimen revealed characteristic features of a tuberculoma with Langerhan’s giant cells and epithelioid cells. Acid-fast bacilli could not be isolated. Postoperatively, the patient was treated with antituberculous treatment [ATT]. The patient progressively improved and her abducens nerve function recovered completely. ATT was continued for 18 months. Repeat cranial CT scan showed complete disappearance of the lesion.