[Cerebral tuberculoma a diagnostic challenge: case study and update]

Central nervous system (CNS) tuberculosis is the second most common presentation after tuberculous meningitis. It is a major cause of morbidity and mortality in the developing countries, accounting for 10-30% of intracranial expansive lesions in these countries against 0.2% in some Western countries. This study aims to report an atypical clinical and radiological manifestation (brain MRI and spectroscopy) of cerebral tuberculoma in order to provide an update on this infectious disease. The study involved a 44-year old female patient with no particular previous history, with headaches persisting for 1 year and complicated by partial secondarily generalized seizures and heaviness at the left hemicorpus with episodes of vomiting without visual disorder or fever or deterioration of general condition after 8 months. Clinical examination showed conscious patient with Glasgow Coma Scale (GCS) 15, equal and reactive pupils, walking and/or standing without fault, with 4/5 left-sided hemiparesis without other neurological signs. Brain MRI objectified right parietal subtentorial plurilobulated isointense poorly differentiated lesion on T1 weighted sequence without contrast agents injection and heterogeneous lesion with hyperintense edge and hypointense fundus, suggesting fleshy process with areas of central necrosis and perilesionnal edema extending in finger-like fashion with intense annular enhancement after gadolinium injection on T2 weighted sequence. Spectroscopy showed glial tumor. The patient received anticonvulsant therapy and macroscopic complete resection. Anatomopathologic analysis showed cerebral tuberculoma. She received antituberculosis drugs with seizure stoppage and deficit recovery after 4 weeks. This study highlights the clinical and radiological polymorphism of cerebral tuberculoma. This is suspected based on laboratory tests as well as on a body of clinical and radiological evidences but definitive diagnosis is based on anatomopathologic analysis. Early management is essential because complications can be severe and result in a poor prognosis.