[Intracranial tuberculoma with spontaneous recovery]

Area of Science:

• Neurology
• Infectious Diseases
• Molecular Diagnostics

Background:

• Tuberculous meningitis (TBM) diagnosis can be challenging, often requiring advanced molecular techniques for early and accurate detection of Mycobacterium tuberculosis.
• Polymerase chain reaction (PCR) assays are recognized for rapid TBM diagnosis, but sensitivity issues with low bacterial loads in cerebrospinal fluid (CSF) persist.
• Evaluating the diagnostic performance of direct versus nested PCR is crucial for improving TBM detection rates.

Observation:

• A 57-year-old male presented with symptoms suggestive of meningitis, including headache, nausea, fever, and nuchal rigidity.
• Cerebrospinal fluid (CSF) analysis revealed elevated white blood cells (monocyte predominance), protein, and ADA levels, with low glucose.
• Brain imaging (CT and MRI) showed a lesion in the right parietal lobe with enhancement patterns suggestive of an inflammatory or infectious process.

Findings:

• Despite initial improvement with antibiotics, Mycobacterium tuberculosis DNA was detected in CSF via PCR amplification, confirming TBM.
• The patient experienced complete recovery following anti-tuberculous treatment, presenting atypical features of spontaneous symptom relief.
• Nested PCR demonstrated superior sensitivity and specificity in detecting M. tuberculosis DNA in CSF compared to direct PCR, successfully identifying the pathogen in all tested TBM cases.

Implications:

• Nested PCR amplification significantly enhances the sensitivity and specificity of diagnosing tuberculous meningitis, addressing limitations of direct PCR.
• This case underscores the importance of molecular diagnostics, like nested PCR, for confirming TBM even in atypical presentations or when initial treatments yield partial results.
• Improved diagnostic accuracy through sensitive PCR techniques can lead to timely and effective anti-tuberculous treatment, improving patient outcomes in TBM.