Frontal lobe syndrome due to "A bunch of grapes".

A 36-year-old female offi ce clerk was admitted with a 6-week history of headache, abnormal behaviour (poor work performance, deteriorating table manners, and lack of social inhibition and frequent repetition of words or phrases) as well as unsteady gait. She also had episodes of urinary incontinence. On examination, she was found to be confused and disoriented. She had positive primitive refl exes (grasp, rooting and palmo-mental refl ex) as well as upper motor neuron type of paraparesis. Routine laboratory investigations were unremarkable and her chest x-ray was normal. MRI brain showed multiple contrast enhancing lesions like " a bunch of grapes " related to the falx cerebri with signifi cant surrounding vasogenic edema (Fig. 1). On further examination, this patient also had several enlarged, matted cervical lymph nodes. Fine needle aspiration of the cervical lymph node showed evidence of caseating granuloma. The acid-fast bacilli (AFB) staining was negative however the follow-on culture was positive for Mycobacterium tuberculosis. A lumbar puncture for cerebrospinal fl uid (CSF) examination was not done in view of the signifi cant cerebral edema and the risk of herniation. A brain biopsy was declined by the patient. She was treated with anti-tubercular drugs and a short course of steroids. She had gradual improvement of headache, cognition and gait. She was able to resume her duties after 6 th months. Discussion The clinical spectrum of patients with intracranial tuberculoma varies according to the location of the lesions. Essentially these patients fall into 2 groups, i.e. those presenting as a space occupying lesion and those presenting with focal seizures, with or without evidence of raised pressure. 1 Intracranial tuberculoma presenting as frontal lobe syndrome (FLS) is not commonly reported. Typically, the syndrome (which was defi ned in 1868 by Harlow) involves general impairment of planning functions, lack of inhibition, hypomanic episodes, impulsiveness, antisocial behaviour, depression, apathy and perseveration (defi ned as uncontrollable repetition of a particular response, such as a word, phrase, or gesture). 2 Our patient's clinical presentation resembled FLS with paraparesis. The MRI of the brain with gadolinium showed evidence of parafalcine ring-enhancing lesions resembling " a bunch of grapes " closely related the falx cerebri with severe surrounding frontal lobe vasogenic edema. Such MR images have been reported to be related to granulomatous infections such as tuberculosis. These ring-enhancing lesions represent the conglomeration of multiple small " immature " tubercles into a more identifi able tuberculomatous …