Atormac
Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 4564  
 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 (961 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this Article
   References
   Article Figures

 Article Access Statistics
    Viewed1006    
    Printed15    
    Emailed0    
    PDF Downloaded27    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents    
LETTER TO EDITOR
Year : 2017  |  Volume : 65  |  Issue : 3  |  Page : 658-660

A rare case of an internal acoustic meatal tuberculoma involving the VII–VIII nerve complex


1 Department of Neurosurgery, Achantha Lakshmipathy Neurosurgical Centre, Voluntary Health Services Hospital, Chennai, Tamil Nadu, India
2 Department of ENT Surgery, Madras ENT Research Foundation, Raja Annamalaipuram, Chennai, Tamil Nadu, India

Date of Web Publication9-May-2017

Correspondence Address:
Gowtham Devareddy
Department of Neurosurgery, Achantha Lakshmipathy Neurosurgical Centre, Voluntary Health Services hospital, TTTI Post, Taramani, Chennai - 600 113, Tamil Nadu
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_1273_15

Rights and Permissions



How to cite this article:
Vasudevan MC, Kameswaran M, Devareddy G, Amarnath D, Krishnan SS. A rare case of an internal acoustic meatal tuberculoma involving the VII–VIII nerve complex. Neurol India 2017;65:658-60

How to cite this URL:
Vasudevan MC, Kameswaran M, Devareddy G, Amarnath D, Krishnan SS. A rare case of an internal acoustic meatal tuberculoma involving the VII–VIII nerve complex. Neurol India [serial online] 2017 [cited 2019 Aug 25];65:658-60. Available from: http://www.neurologyindia.com/text.asp?2017/65/3/658/205895


Sir,

Tuberculoma of the brain and spine is a common entity, however, very few cases of tuberculoma of the nerves have been reported.[1],[2],[3],[4],[5] We report the first case of tuberculoma located in the internal acoustic meatus involving the VII and VIII nerve complex. Extensive literature search was performed, which failed to show a tuberculoma at this location.

A 45-year old gentleman presented with unsteadiness of gait, with a tendency to fall towards the left side, for 2 weeks, followed by difficulty in hearing from the left ear for a week, especially while speaking over the phone. On examination, he had left-sided grade 2 (Houseman and Brackman) lower motor neuron (LMN) facial paresis with a left-sided sensorineural deafness as well as the presence of vestibular signs on the left side. An audiogram and speech discrimination score were carried out, which showed a non-serviceable hearing loss in the left ear. Plain and contrast magnetic resonance imaging (MRI) of the brain showed a small ill-defined lesion in the left internal acoustic meatus, which was hypointense on T1 and T2 images; the lesion was enhancing homogenously [Figure 1].
Figure 1: (a) MRI brain (T1 contrast axial and coronal images) showing an intrameatal lesion with thickening of the VII–VIII nerve complex. (b) Photomicrograph [hematoxylin and eosin (H and E), ×100] showing a caseating granuloma (arrow) and the neural elements (arrow head). (c) Photomicrograph (H and E, ×400) showing the neural elements (arrow) and necrosis (arrow head). (d) Photomicrograph (H and E, ×400) showing the epithelioid cells in the granuloma (arrow head)

Click here to view


A presumptive diagnosis of vestibular schwannoma was made, and because the lesion was <3 cm in size, he was given the option of gamma knife surgery. The patient opted for surgery and underwent total surgical removal of his lesion by the translabyrinthine approach. Intraoperatively, the lesion was grayish and was involving the VII–VIII nerve complex. Furthermore, the lesion was expanding the nerve and the nerve fibres were firmly adherent to the lesion.

Histopathological examination (HPE) of the lesion showed the expanded nerve fibres with multifocal interstitial and perivascular lymphocytic infiltration, along with ill-formed epithelioid cell granulomas with central necrosis suggestive of a tuberculoma [Figure 1].

He had a persisting grade III LMN facial paresis which was improving, along with a left-sided sensorineural deafness. He was further investigated for the presence of tuberculosis and other granulomatous lesions. The tuberculosis quantiferon test was strongly positive with an elevated erythrocyte sedimentation rate, and the high resolution computed tomography of the chest showed apical lesions with fibrosis suggestive of a previous pulmonary tuberculous infection. Serum acetylcholine esterase assay as well as that of antineutrophilic cytoplasmic and antinuclear antibodies were done to rule out other causes of granulomatous diseases, which were found to be negative. The patient was started on antituberculous treatment.

In a patient with tuberculosis, neuropathy occurs as a complication of meningitis, causing the spinal nerve root and cranial neuropathies (especially cranial nerves II, III, VI, VII, and VIII). Neuropathy is attributed to pressure over the nerves and direct effects of the tuberculous exudates on the nerves.[6] In patients with tuberculosis, neuropathy attributable to direct nerve infiltration has been recognized very rarely in peripheral nerves such as the sural nerve, ulnar nerve, median nerve, and the spinal nerve rootlets.[1],[3],[6],[7] A vasculitic neuropathy has also been proposed but no direct evidence of vasculitic abnormality in the nerve has been observed.

Cranial nerve involvement normally occurs in the presence of increased intracranial pressure, and the direct effect of the tuberculous exudate on the nerve. Though optochiasmatic tuberculoma is well documented, only one case has been reported in which the patient had a tuberculoma involving the trigeminal nerve in Meckel's cave, and two cases have been reported involving the cranial nerves in the cavernous sinus.[5],[8],[9],[10]

In our case, the histopathological examination of the lesion showed the expanded nerve fibres with a multifocal interstitial and perivascular lymphocytic infiltration, along with ill-formed epithelioid cell granulomas associated with a central necrosis suggestive of a tuberculoma. The most probable explanation for the development of this lesion was that the tubercle bacilli would have reached the perineurium through the vasa nervosa and would have elicited periarteritis, following which a granuloma had developed. As this phenomenon is extremely rare, the preoperative diagnosis of tuberculous infection of the nerve complex in the internal acoustic meatus is difficult to establish. In the presented case, the characteristic features of a tuberculoma were not present even on gross inspection of the lesion on MRI. As the histological diagnosis was unexpected, a second opinion on the biopsy was sought, which also confirmed the same diagnosis. In our extensive search, there were no reported cases of intrameatal tuberculoma involving the VII–VIII nerve complex.

Tuberculoma of the central nervous is a very common entity, and has myriad manifestations, often with unusual mode of presentations, especially in countries where tuberculosis is endemic. The extremely rare presentation of a direct cranial nerve involvement should also be considered as one of the manifestations of tuberculous affliction.

Acknowledgement

We acknowledge Dr. A. V. Shanti (MD, Pathology) for providing us the necessary colored photomicrographs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Orrell RW, King RH, Bowler JV, Ginsberg L. Peripheral nerve granuloma in a patient with tuberculosis. J Neurol Neurosurg Psychiatry 2002;73:769-71.  Back to cited text no. 1
[PUBMED]    
2.
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. 2
[PUBMED]    
3.
Sinha GP. Tuberculoma of the ulnar nerve. J Bone Joint Surg Am 1975;57:131.  Back to cited text no. 3
[PUBMED]    
4.
Warpe BM, Poflee SV, Pande NP, Shrikhande AV. Tuberculous neuritis: A rare sequel of a common disease. Indian J Pathol Microbiol 2014;57:69-71.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Goel A, Nadkarni T, Desai AP. Tuberculoma in the Meckel's cave: A case report. Neurol India 1999;47:238-40.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Poulose SP, Sugath S, Gopalkrishnan KC. Tuberculosis affecting the median nerve. Kerala J Orthop 2011;24:43-5.  Back to cited text no. 6
    
7.
Peris JB, Wickremasinghe HR, Chandrasekara MA. Tuberculous polyradiculitis. Br Med J 1974;4:107.  Back to cited text no. 7
    
8.
Kadioglu HH, Gundogdu C, Deniz O, Takçi E, Tüzün Y, Aydin IH. Optochiasmatic tuberculoma - Case report and review. Zentralbl Neurochir 1996;57:30-6.  Back to cited text no. 8
    
9.
Morris Jt, Joyee MP. Central nervous system tumour presenting as a cavernous sinus tumour (letter). Clin Infect Dis 1992:15:181-2.  Back to cited text no. 9
    
10.
Phookan G, Towns GM. Tuberculoma of the cavernous sinus - A case report. Br J Neurosurgery 1995;9:205-7.  Back to cited text no. 10
    


    Figures

  [Figure 1]



 

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