Microsoft Word - 10b.BalasaD_Primary_f.docx Romanian Neurosurgery (2012) XIX 1: 63 – 66 63 Primary tuberculomas of the thoracal spinal cord. Case report D. Balasa1, A. Tunas1, A. Terzi2, C. Serban4, M. Aschie3 Clinical Emergency County Hospital, Constanta 1Neurosurgery, 2Anestesiology, 3Pathology 4 Euromedic Private Unit, Constanta, Neuroradiology Abstract The authors present an unusual case of intramedullary tuberculoma in a HIV- negative patient from the southeast part of Romania who demonstrated no other signs of tuberculous infection. Clinical exam: extreme spastic paraparesis in triple flexion, dorsal pain and bladder and bowel incontinence. Gd enhanced MRI revealed ring enhancing lesion with central hypointensity, suggesting granulomatous pathology. Surgical excision of the intramedullary lesions was carried out followed by anti-tuberculous chemotherapy and Baclofen tablets . !0 days postoperative MRI showed total resolution of the lesion. Two years follow up showed progressive resolution of spasticity. Following surgical excision, the patient improved significantly sensitive and modest the motility and spasticity. The management of this rare lesion is discussed and the literature reviewed. Keywords: spinal cord, tuberculosis, primary tuberculomas Intramedullary tuberculomas rest a lesion extremelly rare (2 of 100 000 cases of tuberculosis and 2 of 1000 cases of CNS tuberculosis). Lin and McDonnell (11, 12) found only 148 cases of intramedullary tuberculomas mentioned in the literature. Ratliff (15) present one case of primitive intramedullary tuberculoma. We present the case of un unusual case of intramedullary tuberculoma in a HIV- negative patient from the southeast part of Romania who demonstrated no other signs of tuberculous infection and presents no sign of involvement of the bony spinal canal. Case report Presentation: This 20 years old young peasant male was referred to our department for evaluation of his progressivelly (one year and a half) extreme spastic paraparesis in triple flexion, dorsal pain, bladder and bowel incontinence. There was no history of tuberculosis and he was HIV seronegative. Examination: On examination the pacient acused un severe spastic paraparesis in triple flexion and the right leg more profoundly affected than the left. Patellar and achille relexes was increased. Babinsky sign was positive. Sensory deficit to p inpick and light touch revealed a T4 level right, T5 level left. Chest X-Ray films revealed no abnormalities. Dorsal MRI scan including Gd-DTPA MRI revealed ring enhancing lesion with central hypointensity, suggesting granulomatous pathology from T4 to T5 levels. 64 D. Balasa et al Primary tuberculomas of the thoracal spinal cord Treatment Operation T4-T5 laminectomy, median mielotomy, microsurgical total resection of a well circumscribed yellow-grey mass located cortically and intramedullary. The lesion was very carefully dissected and totally resected along a definable plane by use of the operating microscope. The gross pathological specimen was an encapsulated, yellow-grey firm mass. Pathological findings Ppathological examination of the lesion revealed multiple epitheloid cell granulomas with Langerhan's and foreign body type of giant cells. Large areas of caseous necrosis were seen and necrotic material. Photomicrograph.: Photomicrograph demonstrating epitelioid areas of caseating granulomas with Langhans type giant cells. Van Gieson coloration. Postoperative course Medical treatment: antituberculous chemotherapy for 52 weeks or more consist of four chemotherapeutic agents to overcome drug resistance: INH 300mg/day, rifampin 600 mg/day, etambuthol 1200 mg/day and pyrazinamide 2000 mg/day and antispastic agents (Baclofen tablets). Ten days postoperative MRI showed total resolution of the lesion. The patients improved significantly sensitivity and modest the motility and spasticity. Follow up period: 2 years. Figure 1 Figure 2 Figure 3 Romanian Neurosurgery (2012) XIX 1: 63 – 66 65 Figure 4 Figure 5 Discussion Tuberculosis is a chronic bacterial infection produced by Mycobacterium tuberculosis Tuberculosis of the central nervous system is a rare entity, affecting 0,5-2% of patients with sistemic tuberculosis (14, 3, 15). Intramedullary tuberculomas is a lesion extremelly rare seen only 2 of 100 000 cases of tubeculosis and 2 of 1000 cases of tuberculosis of central nervous systems disesase. It is speciffically for the young patients in the developing countries and is associated usually with pulmonay disease, in 69% of cases (11, 12). The first report of intramedullary tuberculoma was by Abercrombie in 1828 (1) .The commonest symptoms were progressive lower limbs weakness, paresthesia, and bladder and bowel dysfunction. The major physical findings were paraplegia, either spastic or flaccid. The majority of patients had thoracic sensory level. The MRI characteristics have been described by Jena et al (10) as low intensity rings with or without central hyperintensity on T2 images and low to isointense rings on T1 images. Caseation results in the “target sign” appearance. The choice of treatment is an important consideration. Microsurgical total excision and antituberculous agents are widely used in the treatment of intramedullary tuberculoma. MacDonnel has reported 65% recovery after surgical treatment. Conclusion •Intramedullary tuberculoma, is a very rare entity. •Microsurgical total excission and antituberculous chemotherapy consisting of three agents was mandatory for the healing this very large intramedullary lesion. •Motor recovery of this patient is difficult considering the extreme spastic paraparesis in triple flexion and the evolution of the illness of one and a half year. •Will be necessary in time orthopedic procedures for the treatment of spasticity and recovery. Corespondence address Dr. D. Balasa, Department Neurosurgery, Clinical Emergency County Hospital, Boulevard Tomis, 145, Constanta, Romania. E-mail: daniel_balasa@hotmail.com 66 D. Balasa et al Primary tuberculomas of the thoracal spinal cord References 1. Abercrombie J. Pathological and practical researches on disease of the brain and the spinal cord. Edinburg: Waugh and Innes, 1828: 371-2 2. Alex H.MacDonel, Robert W.Baird, Michael S.Bronze. Intramedullary tuberculomas of the spinal cord:Case report and review. Review of infectious diseases. Vol 12,3:432-436,1990 3. Baker RD: Postmortem Examination. Specific Methods and Procedures. Philadelphia, W.B. Saunders, 1967, p 175. 4. B. Indira Devi, S. Chandra, S. Mongia, Chandramouli, K.V.R. Sastry, S. K. Shankar. Spinal Intramedullary Tuberculoma and Abscess: A Rare Cause of Paraparesis. Neurology India, Vol 50, No 4, Dec 2002, 494-496 5. Bertrand I, Guillaume JM, Samson M, Gueguen Y: Tuberculoma Intamedullarire dorsal. Rev Neurol 98:51-54, 1958 6. Citow JS, Ammirati M : Intramedullary tuberculoma of the spinal cord. Case report. Neurosurgery 1994; 35: 3270330 7. Dastur HM. Diagnosis and neurosurgical treatment of tuberculous disease of the CNS. Neurosurg Review. 1983, 6: 111-117 8. GokalpHZ, Ozkal E: Intradural tuberculomas of the spinal cord. J Neurosurg 1985, 55:289 9. Gupta VK, Jena A,Sharma A,Guha DK, Khushu S, Gupta AK: Magnetic resonance imaging of intracranial tuberculomas. J Comput Assist Tomogr 12:280-285, 1988. 10. Jena A, Banerji AK,TripathiRI, Gulati PK, Jain RK, Khushu S, Supra MI. Demonstration of intramedullary tuberculosis By MRI- A case report of 2 cases. Br J Radiol 64:555-557, 1991 11. Lin TH:İntramedullary tuberculoma of the spinal cord . J Neurosurg 17:497-499, 1960 12. MacDonell AH, Baird RW, Bronze MS:Intra Baird RW, Bronze MS: Intramedullary tubercullomas of the spinal cord: Case report and review. Rev Infect Dis 12:432-439, 1990 13. Mohit AA, Santiago P, Rostomily R. Intramedullary tuberculoma mimicking primary CNS 14. Parmar H, Shah J, Patkar D, Varma R.Intramedullary tuberculomas. Mr findings in sevens. patients. Acta Radiol 41:572-7, 2000 15. Ratliff JK: Intramedullary tuberculoma of spinal cord. J Neurosurg(Spine) 1999:90:125-128 16. Whiteman M, Espinosa L, Post MDJ, Bell MD, Falcon S: Central nervous system tuberculosis in HİV infection patient. Clinical and radiographical finding. AJNR Am J Neuroradiol 16:1319-1327, 1995