[A case of intracranial tuberculoma early diagnosed by open brain biopsy]

A 31-year-old man suffered from cough, sputum, slight fever, and loss of consciousness. He was tentatively diagnosed as epilepsy, and was transferred to our hospital. Brain CT demonstrated multiple intracranial lesions, which were homogeneously enhanced. Chest X-ray revealed retiform shadow in the right middle lung field. Pulmonary tuberculosis and intracranial tuberculomas were suspected and bacterial cultures, PCR, smear examination of sputum, blood, CSF, gastric juice, and urine were repeated. But no evidence of tuberculosis was obtained. Follow-up CT after 5 days of admission showed exacerbation of intracranial lesions. Finally, the open brain biopsy was carefully done from the right occipital lesion. The histological examination disclosed a typical pathology of tuberculoma and PCR also turned out to be positive from the brain tissue. We diagnosed him as intracranial tuberculoma and anti-tuberculous drugs(isoniazid, ethambutol, pyrazinamide) were administered. After 30 days under the medication, brain CT demonstrated a transient expansion of the intracranial lesions. While the same therapy was sustained, intracranial lesions gradually decreased and he discharged after 60 days of admission. Brain CT is known as a powerful tool for the diagnosis of intracranial tuberculoma. Its sensitivity is almost 100%, but some clinical reports have described that its specificity is not always so high(20-71%) as expected. In addition, it should be recognized that intracranial tuberculoma might show 'paradoxical expansion'. It is a phenomenon, which shows a paradoxical worsening in clinical aspect despite of the appropriate therapy. In such a progressing case as ours, it is desirable to make a definite diagnosis before anti-tuberculous drug is started. Therefore, it is recommended in possible cases to even consider the open brain biopsy from the early period when intracranial tuberculoma is highly suspected.