Challenging differential diagnosis, Unusual or unexpected effect of treatment
Qi Ying Wong, Andy Sing Ong Tang, Wei Huei Loh, Xin Min Yong, Desmond Samuel, Wan Chung Law, Hock Hin Chua
Department of Internal Medicine, Miri General Hospital, Ministry of Health Malaysia, Miri, Sarawak, Malaysia
Am J Case Rep 2021; 22:e932852
Available online: 2021-06-01
Tuberculosis is prevalent, especially in low-income countries. The most devastating manifestation of tuberculosis is central nervous system (CNS) involvement, albeit rare.
CASE REPORT: We report a rare case of a 26-year-old woman with morbid obesity and hepatitis C who had cerebral tuberculoma and was treated with an extended duration of anti-tuberculosis multi-drug therapy. This patient was initially diagnosed with disseminated tuberculosis of the lungs, liver, and peritoneum. After 4 months of anti-tuberculosis treatment, she developed new right temporal hemianopia and new cerebral tuberculoma, which was identified on repeated magnetic resonance imaging (MRI) and was attributed to tuberculosis-immune reconstitution inflammatory syndrome. The anti-tuberculosis treatment was continued; however, she gained large amounts of weight, which resulted in the failure of the anti-tuberculosis treatment of the cerebral tuberculoma. We decided to adjust the anti-tuberculosis drug dosage using her total body weight, and she responded well, with a decrease in size of the cerebral tuberculoma. The anti-tuberculosis treatment was subsequently stopped after 3 years because of clinical and imaging improvement.
CONCLUSIONS: This case illustrates the challenges faced in the treatment of cerebral tuberculoma, which, in this case, included a high body mass index affecting drug dosage and confounding an inadequate treatment response as seen on interim MRI, resulting in prolonged duration of anti-tuberculosis treatment. Persistent enhancement seen on brain MRI does not equate to treatment failure.
Keywords: Infectious Disease Medicine, Obesity, tuberculoma, Tuberculoma, Intracranial