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|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 6 | Page : 697-699
Giant extra-axial en-plaque tuberculoma with gyriform enhancement: Unusual presentation of a common disease
Amol Raheja1, Shweta Kedia1, Sumit Sinha1, Aruna Nambirajan2, Mehar Chand Sharma2
1 Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
2 Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||10-Nov-2014|
|Date of Decision||14-Nov-2014|
|Date of Acceptance||05-Dec-2014|
|Date of Web Publication||16-Jan-2015|
Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Raheja A, Kedia S, Sinha S, Nambirajan A, Sharma MC. Giant extra-axial en-plaque tuberculoma with gyriform enhancement: Unusual presentation of a common disease. Neurol India 2014;62:697-9
|How to cite this URL:|
Raheja A, Kedia S, Sinha S, Nambirajan A, Sharma MC. Giant extra-axial en-plaque tuberculoma with gyriform enhancement: Unusual presentation of a common disease. Neurol India [serial online] 2014 [cited 2020 Dec 1];62:697-9. Available from: https://www.neurologyindia.com/text.asp?2014/62/6/697/149417
Though first described in 1927, en-plaque tuberculoma still remains a diagnostic dilemma because of its rare occurrence.  This report presents an unusual case of en-plaque tuberculoma mimicking en-plaque meningioma.
A 23-year-old female presented with bilateral painless progressive vision loss along with features of raised intracranial pressure (ICP) for the past 1 year. Neurologic examination revealed bilateral absence of perception of light and evidence of secondary optic atrophy. No history of tubercular contact, trauma, or immunocompromized status was present. Investigations revealed normal chest X-ray, elevated erythrocyte sedimentation rate (ESR) and positive Mantoux test. Contrast magnetic resonance imaging (MRI) of brain revealed a giant (7.6 × 5.4 × 6.5 cm) left frontal, en-plaque, dural-based, extra-axial lesion, isointense on T1 and mild hyperintense on T2 sequences. Contrast study showed gyriform pattern intense homogenous enhancement with deep sulcal extension and significant perilesional edema with mass effect and midline shift [Figure 1] and [Figure 2]. No evidence of hemorrhage, calcification or restricted diffusion was seen within lesion. With a presumptive diagnosis of tuberculoma versus meningioma; frontal craniotomy and complete excision of dural-based, firm, grayish, moderately vascular lesion was done. Histopathology revealed a necrotising granulomatous inflammation with presence of acid fast bacilli on Ziehl Neelson staining, thus confirming the diagnosis of tuberculosis [Figure 3]. She was discharged on anti-tubercular therapy (ATT) with uneventful post-operative course.
|Figure 1: Axial (a), Coronal (b), and Saggital (c) T2 weighted magnetic resonance imaging (MRI) brain revealing mildly hyperintense left frontal, dural-based, extra-axial, enplaque lesion with gyriform pattern and sulcal extensions (marked as asterisk). Note is made of hyperintense massive white matter edema, mass effect, and midline shift of 15 mm to right side|
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|Figure 2: Axial (a), Coronal (b), and Saggital (c) T1 weighted post gadolinium magnetic resonance imaging (MRI) brain revealing left frontal, dural based, enplaque lesion with solid intense gyriform enhancement, and sulcal extensions (marked as arrow). Note is made of hypointense massive white matter edema, mass effect, and midline shift to right side|
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|Figure 3: (a) H and E x40 (b) H and E, x100 (c) H and E, x 400 show a necrotising granulomatous inflammation with langhan giant cells and epithelioid cell granulomas (d) Ziehl Neelson stain shows presence of an occasional acid fast bacillus (x 600)|
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First described by Pardee and Knox in 1927, en-plaque tuberculoma is essentially a plaque with meningitic process without exudation leading to formation of solid mass with no calcification or caseation.  Pathophysiology involves haematogenous seeding of leptomeninges by tubercular bacilli, formation and coalition of tuberculoma with reactionary fibrous capsule formation.  Limited case reports ,,,, of this rare entity are present with convexity dura, falx, and tentorium being the commonly affected sites. Raised ICP, seizures, and focal neurological deficits are the usual presenting features. Solid intense dural-based enhancement in such lesions mimics en plaque meningioma, lymphoma, metastasis, arteriovenous malformation, sarcoidosis, and empyema; thereby making computed tomography (CT) and MRI based differentiation difficult at times. ,, Addition of MR spectroscopy and polymerase chain reaction (PCR) analysis to spectrum of investigation used may increase pre-operative diagnostic accuracy. , ATT forms the first line treatment for such lesions and surgery reserved only for cases with diagnostic dilemma, mass effect, failure of ATT, and suspicion of multi-drug resistant tuberculosis. ,, Neuro-imaging highlights the T2 hyperintense and solid intense gyriform enhancement of this rare form of intracranial tuberculoma as opposed to T2 hypointense core and ring like heterogenous enhancement in more commonly observed brain tuberculomas. 
Early recognition of this unusual presentation of intracranial tuberculoma may facilitate prompt diagnosis and appropriate management. In the index case, surgical evacuation not only established histological diagnosis but also alleviated the compressive symptoms.
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[Figure 1], [Figure 2], [Figure 3]
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