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A 35‐year‐old male presented with lower back pain, progressive weakness of the ankles, loss of pain, temperature and touch sensation on the medial aspect of the legs, dorsum of the foot and soles, and urinary urgency, frequency and urge incontinence. Ankle dorsiflexors and plantar flexors showed grade 4/5 power with only minimal weakness of knee extension. Bilateral ankle jerks were diminished. Bilateral L3–S1 dermatomes showed 50–70% sensory loss to pain, temperature and touch. The Mantoux test was positive. No chest symptoms or signs were present. CSF examination revealed mild lymphocytosis (20 cells/mm3), elevated proteins (110 mg/dl) and low glucose (40 mg/dl with a blood glucose of 140 mg/dl). CSF Gram stain and bacterial culture were negative.
MRI of the spine showed an intramedullary conglomerate of cystic lesions at the T11–12 vertebral level (fig 11).). Acid fast stain of CSF was negative but CSF culture for Mycobacterium tuberculosis was positive. CSF–PCR for tuberculosis was positive (fig 22).). Chest radiographs were normal. Following a diagnosis of spinal tuberculosis (intramedullary tuberculoma), the patient was started on antituberculosis chemotherapy along with oral corticosteroids. Isoniazid, rifampicin, ethambutol and pyrazinamide were given for the first 3 months followed by isoniazid and rifampicin for 5 months. Corticosteroids were given for 6 weeks and gradually stopped. The patient started showing improvement following 2 weeks of initiation of therapy with continued improvement during the course of treatment and was completely asymptomatic after the full course of treatment. Follow‐up MRI could not be done because of unwillingness of the patient who is being followed‐up clinically and there is no recurrence of symptoms after 6 months of completion of therapy.
Intramedullary tuberculomas, although well known, are an uncommon occurrence.1,2 They have a typical appearance of “ring enhancing lesions” on MRI and the differential diagnosis includes neoplastic, demyelinating, vascular, inflammatory and other granulomatous lesions.3 In our case, CSF culture for Mycobacterium tuberculosis and PCR confirmed the diagnosis along with the typical MRI appearance of the lesion.
Competing interests: None.