Brain tuberculoma: Report of a case presented with prolonged nonspecific symptoms and multiple brain tuberculoma

Five decades of tuberculosis control programs using potentially effective medications have been unsuccessful in diminishing the prevalence of the infection in most parts of the world and tuberculosis continues to kill all age groups.1 Tuberculosis may manifest with atypical clinical manifestations and delayed diagnosis may give rise to unexpected grave outcomes. As a result, high degree of clinical suspicion is required to prevent late diagnosis. A 18-year-old girl was admitted to the department of neurology at Sina Hospital (a teaching hospital of Tehran University of Medical Science, Tehran, Iran) with chief complaints of fever and headache. The patient had been well till three months before admission, when she developed malaise and anorexia. After two months, she got paresthesia in lower extremities and two weeks later was admitted at a local hospital. The physicians noted mild spastic paraparesis without any other abnormality on physical examination, chest radiography, spinal neuroimaging and routine laboratory examinations. Therefore, she received high doses of methylprednisolone, with the impression of possible multiple sclerosis, but headache and projectile vomiting were added to her previous problems and she was referred to our hospital. On admission, the patient also complained of weight loss and night sweating. On physical examination, she was generally wasted and drowsy. She had oral temperature of 38°C, pulse rate of 90 per minute, respiratory rate of 16 per minute and blood pressure of 110/80 mmHg and neck stiffness was present. No obvious abnormalities were detected in lung, heart, and abdomen and extremities examination. The patient was oriented but sleepy. Cranial nerves were intact. Right sided hemiparesis, with the proximal and distal strength of 4 out of 5 was detected and bilateral Babinski sign was present. Sensory and cerebellar exams were normal. She had only a hemiparetic gait. Brain computerized tomographic scan (CT-scan) showed multiple small enhancing lesions in supraand infra-tentorial structures, but there was no hydrocephalus. Brain magnetic resonance imaging (MRI) revealed similar lesions with no dural enhancement (Figure 1). These lesions were highly intense on T2 weighted MRI. The differential diagnoses included multiple brain abscess, multiple