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Glioma mimicking a tuberculoma.
CT scan has revolutionized treatment of intracranial space occupying lesions by providing a reasonable percentage of definite diagnosis based on the appearances of the lesion. Of the lesions described, the various manifestations of intracranial tuberculosis have been extensively described.[1] The authors present a case of glioblastoma mimicking a Tuberculoma on CT and clinical presentation. A 30 year-old patient was admitted with a history of sudden onset seizures lasting few minutes with no post-ictal weakness. There was no prior history of seizures or headaches. On examination he was conscious, oriented and had no focal deficits. CT scan of the brain showed a hypodense lesion with an adjacent mildly hyperdense lesion abutting the frontal horn on the right side. On contrast, the lesion enhanced well peripherally, but intralesional hypodensity persisted. The hyperdense lesion did not show much enhancement. There was grade II perilesional oedema with compression of the ipsilateral ventricle [Figure 1]. In view of the CT findings, the patient was started on anti tubercular drugs. To get a definite diagnosis, a right frontal craniotomy was done. The lesion was subcortical. Macroscopically, it was greyish, mildly vascular and had central necrosis. The cystic lesion was removed till white matter was seen all around. He did well postoperatively. Histopathological examination revealed a glioblastoma multiforme. There was no evidence of AFB or other features suggestive of tuberculosis. He was irradiated and is doing well. The CT morphology of intracranial tuberculomas has been well documented since 1976.[2] The important manifestations being isodense to hypodense on plain CT with enhancement on contrast. The enhancement may be ring, nodular or disc type. Multiple lesions of probably different characteristics occurring in the same patient have been seen in 15-20%.[3] Peripheral oedema is usually prominent. The case described here had features of multiple lesions and suggested a tuberculoma. Glioblastomas are also usually mixed density lesions with poor margins and enhance irregularly with contrast. Variable enhancement has also has been described viz nodular, annular or mixed.4 These lesions are usually single and multiple lesions though described, are rarely adjacent.[5] Tuberculomas are known to mimic gliomas. Brismar et al had a large number of patients who were referred for surgery for brain tumours and were finally diagnosed as tuberculomas.[6] In developing countries, it is justified in making a diagnosis of tuberculoma in patients with intracranial mass lesions. Tumours are also known to mimick tuberculomas. There have been various reports of intracranial mass lesions occurring inspite of chemotherapy.[7] When a CT scan shows all features suggestive of a tuberculoma, patient is usually put on antitubercular treatment. However, as in our case, a glioma masquerades as a tuberculoma, valuable time would have been lost with anti tubercular drugs. The authors feel, it is prudent to get a MRI/MRI spectroscopy done in a mass lesion. If MRI is also inconclusive, a stereotaxic or excision biopsy is mandatory. The lesion may be actually a glioma mimicking a tuberculoma.
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