Journal of Global Infectious DiseasesOfficial Publishing of INDUSEM and OPUS 12 Foundation, Inc. Users online:16  
Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size     
Home About us Editors Ahead of Print Current Issue Archives Search Instructions Subscribe Advertise Login 
 


 
   Table of Contents     
CASE REPORT  
Year : 2012  |  Volume : 4  |  Issue : 1  |  Page : 75-78
Suprasellar tuberculoma presenting as sudden onset blindness in a patient of lupus


Department of Medicine, Medical College Kolkata, 88 College street, Kolkata, West Bengal, India

Click here for correspondence address and email

Date of Web Publication13-Mar-2012
 

   Abstract 

Tuberculosis can be an opportunistic infection complicating the course of patients receiving prolonged immunosuppression. In these patients, the tuberculosis can involve the central nervous system and can cause diagnostic difficulty due to atypical features. Often, the diagnosis of central nervous system tuberculosis in resource limited settings is indirect, like imaging. But anti-tubercular drugs, given even on empirical basis can be life saving. A case of a young female systemic lupus erythematosus patient (on prolonged steroids) with intracranial tuberculoma is presented here. She presented with blindness and headache and her computed tomography scan showed a calcified mass in the suprasellar location. However, she responded well to anti-tubercular drugs. The differential diagnoses of such lesions are also discussed.

Keywords: Lupus, Suprasellar calcification, Tuberculosis

How to cite this article:
Paul R, Banerjee AK, Bandyopadhyay R. Suprasellar tuberculoma presenting as sudden onset blindness in a patient of lupus. J Global Infect Dis 2012;4:75-8

How to cite this URL:
Paul R, Banerjee AK, Bandyopadhyay R. Suprasellar tuberculoma presenting as sudden onset blindness in a patient of lupus. J Global Infect Dis [serial online] 2012 [cited 2019 Jul 20];4:75-8. Available from: http://www.jgid.org/text.asp?2012/4/1/75/93766



   Introduction Top


Systemic lupus erythematosus needs prolonged immunosuppressive therapy for control of symptoms. However, this immunosuppressed condition can predispose the patient to opportunistic infections like tuberculosis. In these patients, tuberculosis can affect different systems and can have uncommon clinical presentations. A case of a young female of lupus (on steroids) with suprasellar tuberculoma is described here. She presented with blindness and intense headache.


   Case Report Top


A 22-year-old female was admitted through emergency with sudden onset severe headache, vomiting, and dimness of vision (6/60) in both eyes. She was diagnosed with systemic lupus erythematosus one year ago by clinical and laboratory criteria (ACR) with nephropathy grade three. She had been given pulse cyclophosphamide 1 year earlier (6 doses, 21 days apart each). After that, she was put on oral steroids (prednisolone, 7.5 mg/day oral) and she continued the drug in the intervening period. At the time of admission she was still on oral steroids (7.5 mg/day). She had no other manifestations of lupus and her mental status was normal. She also had no prior visual problems.

After admission, the patient developed low grade fever and her dimness of vision progressed. By third day, she had no perception of light in either eye. Local examination of the eyes showed pupils to be dilated and non-reactive. Ophthalmoscopy showed mild papilledema bilaterally. No neck rigidity was elicited. There was bilateral sixth cranial nerve weakness; but no other neurological signs. Ophthalmologists opined that the pathology was not intra-ocular; neurologists were of the opinion that there was a vascular event in cranium. Immediate imaging was advised.

Routine laboratory tests showed mild anemia and thrombocytopenia. Her blood glucose was raised (fasting=144 mg/dL), probably due to long intake of steroids. Due to the presence of papilledema, we did a CT scan of brain [Figure 1] which showed a calcified mass in suprasellar region with perilesional edema (black arrow) with obstructive hydrocephalous. There was also mild cerebral atrophy. The Mantoux test of the patient was negative (she was on steroids), sputum did not show any acid-fast bacilli and chest X-Ray was also normal. She had contact with a sputum positive case of tuberculosis 3 months ago. Her hormonal profile was normal. We could not attempt a spinal tap due to hydrocephalous. The Magnetic resonance imaging scan could not be done due to cost factor. In view of the emergent nature of the illness, we started her on oral anti tubercular drugs with an increased dose of oral steroids. Her headache decreased, but vision improved only mildly. Subsequently, after 1 month, a brain biopsy was done and the lesion was found to be calcified granuloma with aggregates of epitheloid cells, calcifications, necrosis, blood vessel destructions, and few scattered caseations [Figure 2]. The lesion did not show any acid fast bacilli, but overall features were suggestive of tuberculosis. A CSF sample collected at time of brain biopsy showed increased cells (45/μL), increased protein (102 mg/dL). AFB stain of CSF was negative; a PCR from CSF was positive for mycobacterium tuberculosis. Repeat CT scan [Figure 3] showed only a mild decrease in the size of the edema; calcified mass size was the same. She was put on anti-tubercular drugs for 1 year. At present her vision is finger counting at three feet.
Figure 1: The CT scan of the patient showing suprasellar calcified mass (upper left and upper right panels, perilesional edema (black arrow), and hydrocephalous (white arrow, right lower panel)

Click here to view
Figure 2: Brain biopsy slide showing lymphocytes and areas of necrosis

Click here to view
Figure 3: Repeat CT scan of the patient after 5 months, showing only decrease of edema, calcification size same

Click here to view



   Discussion Top


Tuberculomas are an important cause of space occupying lesions in brain in developing countries like India. In cases like ours, with no extra cranial manifestations of tuberculosis, diagnosis can be difficult and only suggested by CT scans. For confirmation, a stereotactic brain biopsy can be attempted. [1] However, non-invasive methods like PET scan can be useful; if CSF study can be done, PCR or ELISA for Mycobacterium tuberculosis from the fluid can be attempted. Tuberculosis of central nervous system can have different forms like meningitis, abscess, tuberculoma, subdural collection or miliary form. [2] The abscess or tuberculoma may heal with calcification. These parenchymal lesions can also cause obstructive hydrocephalous. [3] Suprasellar tuberculoma can present with diabetes insipidus, visual loss, or hypothyroidism. In resource-limited settings, and when the patient is severely ill, often diagnosis is not possible and empirical treatment is needed. Steroids are usually indicated in these cases. Surgery may also be needed. Calcified mass in brain seen in CT scan can have many etiologies. [4] The following chart [Table 1] shows the different common etiologies of cerebral calcification and their differentiation with special reference to suprasellar lesions:
Table 1: Table Showing the characteristics of different lesions with cerebral calcification

Click here to view


Suprasellar lesions can present with hypogonadism, features of raised intracranial pressure and hemianopia. But sudden visual loss is quite rare. Also, lesions with an infective cause should be differentiated from calcified tumors and aneurysms because drug treatment is helpful in tuberculoma, whereas in other cases prompt surgery is the only option. The idea of presenting this case is to draw attention on the catastrophic effects of long-term steroids. Although tuberculosis is a known complication of long-term immunosuppression, tuberculomas are rare and suprasellar tuberculoma causing visual impairment is indeed very rare. A case like ours was reported from India by Sharma et al in 2003. [14] Their patient had permanent visual loss. Very rarely, tuberculomas are found near optic chiasm, but when they occur, they can cause these catastrophic consequences. [15] Another similar case was recently reported. [16] In that case, adalimumab treatment resulted in tuberculoma and the patient presented with dyspraxia. However, fortunately, that case was diagnosed before the calcification stage and the patient responded favorably to drugs.

Also, intracranial calcification is a vexing problem in a resource limited settings. Proper differentiation of the lesions in CT scan is important to the treating physician. In a resource limited setting, anti-tubercular drug, even on empirical basis can be life saving and should be used without delay. Newer diagnostic methods like PET scan can also help in distinguishing these lesions (tuberculosis has lower FDG uptake than lymphoma). [17] MR spectroscopy can also help in this regard; tuberculoma shows prominent lipid peak at 1.3 ppm. [18]

The lesion of tuberculosis will show significant change in subsequent imaging following therapy although the radiological resolution may not match with the clinical improvement, especially in central nervous system lesions. Specially calcified lesions often indicate irreversible damage. These patients should be followed up for development of epilepsy.


   Conclusion Top


This case shows the importance of brain imaging in suspected infective disorders and the need to interpret the images quickly for maximum benefit of the patients. Especially in the background of the immunosuppressed state, any infection (like tuberculosis) can present with a catastrophe like blindness and timely therapy can prevent subsequent morbidity to a large extent. At times, empirical therapy can also be used, provided clinical suspicion is strong and diagnostic tests are unavailable or impractical. Also, clinicians need to be well versed with the differential diagnoses of intra cranial calcification, which, though a common finding, can be a diagnostic dilemma at times.

 
   References Top

1.Haddadian K, Rezaei O, Samadian M. Multiple brain tuberculomas and role of open brain biopsy: A case report and review. The Internet Journal of Infectious Diseases. 2005;4: [about 1 p]. Available from: http://www.ispub.com/journal/..../multiple_brain_tuberculomas_and_role_of_open_brain_biopsy_a_case_report_and_review.html [Last cited on 2010, Dec 23].  Back to cited text no. 1
    
2.Garg RK. Tuberculosis of the central nervous system. Postgrad Med J 1999;75:133-40.  Back to cited text no. 2
    
3.Khoo JL, Lau KY, Cheung CM, Tsoi TH. Central nervous system tuberculosis. J HK Coll Radiol 2003;6:217-28.  Back to cited text no. 3
    
4.Kýroglu Y, Çallý C, Karabulut N, Öncel C. Intracranial calcifications on CT. Diagn Interv Radiol 2009;16:263-9.  Back to cited text no. 4
    
5.Ketonen L, Koskiniemi ML. Gyriform calcification after herpes simplex virus encephalitis. J Comput Assist Tomogr 1983;7:1070-2.  Back to cited text no. 5
    
6.Khan AN, Turnball I, Al-Okaili R, Macdonald S. Imaging in CNS Toxoplasmosis: Imaging. WebMD; 2010 Available from: http://emedicine.medscape.com/article/344706-imaging. [Last Cited on 2010 Dec 24].  Back to cited text no. 6
    
7.Hwang T, Valdivieso JG, Yang CH, Wolin MJ. Calcified brain metastasis. Neurosurgery 1993;32:451-4.   Back to cited text no. 7
    
8.Sinha VD, Dharker SR, Pandey CL. Congenital intracranial teratoma of the lateral ventricle. Neurol India 2001;49:170.  Back to cited text no. 8
[PUBMED]  Medknow Journal  
9.Anderson JR. Intracerebral calcification in a case of systemic lupus erythematosus with neurological manifestations. Neuropathol Appl Neurobiol 1981;7:161-6.  Back to cited text no. 9
    
10.Iwaski Y, Kinoshita M, Takamiya K. Rapid development of basal ganglia calcification caused by anoxia. J Neurol Neurosurg Psychiatry 1988;51:449-50.  Back to cited text no. 10
    
11.Kotan D, Aygul R. Familial Fahr disease in a Turkish family. South Med J 2009;102:85-6.  Back to cited text no. 11
    
12.Lee KF, Sub JH. CT evidence of grey matter calcification secondary to radiation therapy. Comput Tomogr 1977;1:103-10.  Back to cited text no. 12
    
13.Kieslich M, Errázuriz G, Posselt HG, Moeller-Hartmann W, Zanella F, Boehles H. Brain white-matter lesions in celiac disease: A prospective study of 75 diet-treated patients. Pediatrics 2001;108:E21.  Back to cited text no. 13
    
14.Sharma K, Pradhan S, Varma A, Rathi B. Irreversible blindness due to multiple tuberculomas in the suprasellar cistern. J Neuroophthalmol 2003;23:211-2.  Back to cited text no. 14
    
15.Lesoin F, Dubois F, Rousseaux M, Pasquier F, Petit H, Jomin M. Chiasmatic tuberculoma. 2 cases. Semin Hop Paris 1984;60:1185-8.   Back to cited text no. 15
    
16.Lynch K, Farrell M. Cerebral tuberculoma in a patient receiving anti-TNF alpha adalimumab treatment. Clin Rheumatol 2010;29:1201-4.   Back to cited text no. 16
    
17.Villringer K, Jäger H, Dichgans M, Ziegler S, Poppinger J, Herz M, et al. Differential diagnosis of CNS lesions in AIDS patients by FDG-PET. J Comput Assist Tomogr 1995;19:532-6.   Back to cited text no. 17
    
18.Saini KS, Patel AL, Shaikh WA, Magar LN, Pungaonkar SA. Magnetic resonance spectroscopy in pituitary tuberculoma. Singapore Med J 2007;48:783.  Back to cited text no. 18
    

Top
Correspondence Address:
Rudrajit Paul
Department of Medicine, Medical College Kolkata, 88 College street, Kolkata, West Bengal
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-777X.93766

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

Top
  
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed2288    
    Printed116    
    Emailed1    
    PDF Downloaded15    
    Comments [Add]    

Recommend this journal

Sitemap | What's New | Feedback | Copyright and Disclaimer | Contact Us
2008 Journal of Global Infectious Diseases | Published by Wolters Kluwer - Medknow
Online since 10th December, 2008