Atormac
Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 10536  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
  
 Resource Links
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Article in PDF (1,002 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this Article
   References
   Article Figures
   Article Tables

 Article Access Statistics
    Viewed1646    
    Printed20    
    Emailed0    
    PDF Downloaded45    
    Comments [Add]    
    Cited by others 1    

Recommend this journal

 


 
Table of Contents    
LETTER TO EDITOR
Year : 2015  |  Volume : 63  |  Issue : 2  |  Page : 268-270

Ulnar nerve tuberculoma masquerading as a neurofibroma


1 Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Plastic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication5-May-2015

Correspondence Address:
Ashim Das
Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.156305

Rights and Permissions



How to cite this article:
Chatterjee D, Lath K, Sharma RK, Das A. Ulnar nerve tuberculoma masquerading as a neurofibroma. Neurol India 2015;63:268-70

How to cite this URL:
Chatterjee D, Lath K, Sharma RK, Das A. Ulnar nerve tuberculoma masquerading as a neurofibroma. Neurol India [serial online] 2015 [cited 2019 Aug 20];63:268-70. Available from: http://www.neurologyindia.com/text.asp?2015/63/2/268/156305


Sir,

Tuberculous involvement of the peripheral nerve is extremely rare. A patient with an ulnar nerve tuberculoma was mistakenly diagnosed to be having a neurofibroma based on clinical examination and magnetic resonance imaging (MRI).

A 42-year-old patient presented with a 4-month history of a gradual onset weakness of the right hand and forearm. There was associated paresthesia and tingling sensation on the medial aspect of the hand. Gradually, the patient developed an ulnar claw hand. On neurological examination, there was loss of power on the medial aspect of hand and medial two fingers along with atrophy of the medial aspect of forearm and the hypothenar muscles. There was loss of pain, touch, temperature, and vibration sensation in the right forearm and hand along the ulnar nerve distribution.

On palpating the ulnar nerve, its focal thickening and swelling were noted on the posteromedial aspect of the arm just above the elbow. The swelling was fusiform in shape, well-defined, and measured 5 × 3 cm. The MRI showed a well-encapsulated, fusiform mass in relation to the ulnar nerve, that was hyperintense on T1WI and hypointense on T2WI signal [Figure 1]a and b. The clinical and radiological impression was that of a benign peripheral nerve sheath tumor, possibly a neurofibroma. The mass was excised under general anesthesia. An intracapsular excision of the mass was done with a few nerve fascicles (3 mm) proximal and distal to the lesion. On gross examination, the lesion was well-encapsulated and fusiform in shape. The cut surface was homogenous and showed a granular, caseous material in the center. The histopathological examination showed a well-encapsulated lesion with peripherally compressed nerve fibers. The lesion showed large areas of necrosis in the center surrounded by palisading histiocytes, occasional ill-formed epithelioid cell granulomas and a few Langhans giant cells [Figure 1]c and d. The Zeihl-Neelsen stain did not reveal any acid-fast bacilli.The lepra stain was negative. The overall morphology was consistent with a tuberculoma.
Figure 1: (a) Axial T1WI MRI of the right lower arm showing a hyperintense lesion in relation to the ulnar nerve. (b) Coronal fat-suppressed T2WI of right elbow shows a hyperintense lesion on the ulnar aspect of the lower arm in relation to ulnar nerve. (c) Histopathological examination shows a well-encapsulated lesion with large areas of central necrosis (H and E, × 4). (d) Peripheral area shows ill-formed epithelioid cell granulomas admixed with lymphocytes (H and E, × 20). T1WI = T1-weighted imaging, T2WI = T2-weighted imaging, H and E = hematoxylin and eosin

Click here to view


On further evaluation, the patient denied any history of previous tuberculous infection or contact with patient suffering from tuberculosis. The Mantoux test was, however, positive. The patient was started on antituberculous therapy (ATT). At a 4-month follow up, the patient showed significant improvement in his sensory and motor functions. The residual deformity of the hand persisted.

Tuberculomas of the central nervous system (CNS) are more commonly seen in children and the preferred site is the cerebellum. Tuberculomas may also be seen within the spinal cord. Compared with its occurrence in the CNS, involvement of the peripheral nervous system is very uncommon. Secondary involvement of the nerve from an adjacent lymph node, bony, or soft tissue tuberculous abscess may be seen. However, a tuberculoma of a peripheral nerve is an extremely rare phenomenon. Only four cases of peripheral nerve tuberculomas have been reported in the English literature and all of them showed involvement of the ulnar nerve [Table 1]. [1],[2],[3],[4] Radiological imaging was available only in one case, that showed features similar to our patient. [4] Systemic tuberculous involvement was not present in 3 out of the 4 reported cases. [1]
Table 1: Case review of a peripheral nerve tuberculoma


Click here to view


The pathogenesis of a peripheral nerve tuberculoma is debatable. The epineurium is tough making it difficult for the tuberculous bacilli to penetrate it. It is believed that a tuberculoma involving a nerve is always secondary, possibly arising as a result of vascular dissemination from a primary focus (often residing in the lung). The primary focus is not detectable in a majority of the cases by imaging or other modalities as it may have either healed or may have been present as a very small, subclinical entity. The two cases reported in literature had a history of local trauma and contact with tuberculosis. [3],[4] Local trauma may rarely be responsible for direct inoculation of the bacilli.

The preoperative diagnosis of a peripheral nerve tuberculoma may be difficult to establish because of rarity of this entity. The final diagnosis comes from the histopathological examination that reveals a central area of necrosis surrounded by epithelioid histiocytes, granulomas with or without giant cells. A complete intracapsular excision followed by antitubercular therapy can result in a good recovery of motor and sensory functions. The compilation of more cases with adequate radiological information would help to increase awareness of this entity and achieve an accurate preoperative diagnosis.

 
  References Top

1.
Hasan SA, Prakash VE. Tuberculoma of the ulnar nerve. A new clinical entity. J Int Coll Surg 1964;42:30-4.  Back to cited text no. 1
    
2.
Sinha GP. Tuberculoma of the ulnar nerve. J Bone Joint Surg Am 1975;57:131.  Back to cited text no. 2
[PUBMED]    
3.
Nucci F, Mastronardi L, Artico M, Ferrante L, Acqui M. Tuberculoma of the ulnar nerve: Case report. Neurosurgery 1988;22:906-7.  Back to cited text no. 3
    
4.
Ramesh Chandra VV, Prasad BC, Varaprasad G. Ulnar nerve tuberculoma. J Neurosurg Pediatr 2013;11:100-2.  Back to cited text no. 4
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1]

This article has been cited by
1 Ulnar nerve tuberculoma: A case report and literature review
Mingzhi Song,Xiaohong Sun,Ran Sun,Tao Liu,Gang Li,Song Liu,Ming Lu,Wei Qu
Journal of Clinical Neuroscience. 2016; 32: 130
[Pubmed] | [DOI]



 

Top
Print this article  Email this article
   
Online since 20th March '04
Published by Wolters Kluwer - Medknow