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 TUBERCULOMA IN PREGNANCY

Anahita Pandole*, Ranjit Akolekar **,Nischal Vaidya***, Shailesh Kore***, VR Ambiye****
*Lecturer; **Registrar; ***Associate Professor; ****Hon. Professor and Head of Unit; Department of Obstetrics and Gynaecology, LTMG Hospital, Sion, Mumbai - 22.

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Tuberculoma is second only to neoplastic lesions as a cause of raised intracranial tension. Tuberculosis is quite common in developing countries. It is therefore quite likely that a pregnant patient with history of convulsions may have tuberculoma. We had a similar case of a term pregnancy with history of convulsions. CT scan clinched the diagnosis of tuberculoma. The patient was delivered by caesarean section and later was operated for removal of the tuberculoma. The diagnosis of tuberculoma was confirmed later on histopathology.

 

INTRODUCTION

Tuberculoma is second only to neoplastic lesions as a cause of raised intracranial tension. Tuberculosis being quite common in developing countries, makes tuberculoma quite a likely diagnosis in many patients with symptoms of raised intracranial pressure. Patients present with signs of raised intracranial tension or localizing symptoms or signs. The situation becomes more complex when patient with tuberculoma is pregnant. Because of similarity in clinical presentation, it may at times be confused with eclampsia, which is a more common cause of convulsions during pregnancy. Hence, a diagnosis of tuberculoma may be missed during pregnancy unless a thorough neurological examination is done.

CASE REPORT

Mrs. XYZ, a 19 year old patient, primigravida, residing at Dharavi, Mumbai was transferred from Chhatrapati Shivaji Hospital, Kalwa with history of two episodes of convulsions with eight months of amenorrhoea. The convulsions were generalized tonic and clonic in nature. She had no history of any trauma or head injury in the recent past. There was no associated headache preceding the convulsions. There was no history of any such similar complaint in the past. She had no history of hypertension or PIH during her antenatal period. She had no major obstetric complaints. She had eight months of amenorrhoea, was antenatally registered. There was no history of leaking or bleeding per vaginum. She could perceive good foetal movements.

On examination, her general condition was unsatisfactory. The patient was conscious but was drowsy. She was oriented and co-operative. She was afebrile. Her pulse was 90 bts/min and she was normotensive. There was no tachypnoea. There was minimal pallor. There was no pedal oedema. Her pupils were equally reacting to light. Fundus examination was normal. There was no facial paresis and her facial sensations were normal. Power was assessed in both the upper and lower limbs and was 5/5. Knee jerks were normal.

On obstetric examination, the uterus was 34 weeks of gestation, with cephalic presentation. The foetal heart was regular, 144 per min. Per vaginal examination revealed that the cervix was poorly effaced and the external os admitted one finger but the internal os was closed. There was no sign of any leak.

Complete haemogram was normal. Other routine investigations were also normal. CSF examination was normal and there was no evidence of meningitis. CT study revealed a fairly well defined ring enhancing, isodense lesion in the peripheral left temporal lobe, measuring 3.6 x 2.2 cms. Another similar ring enhancing lesion was seen in the left high parietal lobe, measuring 4.0 x 2.3 cms (Fig. 1). Findings were suggestive of tuberculoma. A chest radiograph was done and was suggestive of pulmonary Koch’s.

A neurosurgery reference was taken and a decision was taken to terminate the pregnancy followed by excision of the tuberculoma. An elective caesarean section was done on the patient to avoid any straining during labour. There were no intraoperative or post-operative complications. Excision of tuberculoma was planned and a left fronto-temporoparietal craniotomy with excision of tuberculoma in temporoparietal region with duroplasty was done five days following caesarean section.

Histopathology examination of the intracranial mass was done and the clinical diagnosis of tuberculoma was confirmed (Fig. 2).

Fig 1 : CT Scan shows left temporal lobe tuberculoma.[Isodense ring enhancing lesion in the left temporal lobe ].	Fig 2 : Histopathology of tuberculoma

 

The post-operative stay was uneventful and the patient was discharged in good condition on the seventh post-operative day. The patient was started on antitubercular drugs.

DISCUSSION AND CONCLUSION

Tuberculoma is second only to neoplastic lesions as a cause of raised intracranial pressure. It may occur in both, the supratentorial and infratentorial compartments. Patients may present with signs of raised intracranial pressure or with localizing signs and symptoms. [4]

In all cases where the diagnosis of tuberculoma is being considered, anciliary evidence for tuberculosis should be looked into and a CSF examination should be carried out unless it contraindicated because of papilloedema.

Tubercular aetiology is difficult to prove. Diagnosis at times is based on a history of contact in the family or a positive tuberculin test.

The diagnosis is more difficult during pregnancy. More commonly eclampsia becomes the presumptive diagnosis in patients with convulsions during pregnancy, unless other differential diagnosis are kept in mind and specifically looked for. [2] Patients with tuberculoma are usually normotensive and do not have proteinuria. A CT scan or MRI is usually necessary and clinches the diagnosis with proper clinical correlation.3 It is possible to differentiate a tuberculoma from other neoplastic lesions in the brain which may give rise to a similar clinical presentation.

On a CT scan, an increased attenuation, an isodense ring or a disc lesion with perilesional oedema which persists for few weeks and is not a post ictal phenomenon strongly suggests the diagnosis of a tuberculoma. [1]

ACKNOWLEDGEMENT

We thank our Head of Department and Dean for allowing us to use and publish the hospital data.

REFERENCES

1. Draouat S. Computed tomography of cerebral tuberculoma. J Comput Assist Tomogr 1987; 11 (4) : 594-7.

2. Reimers D. Tuberculosis in pregnancy. Prax Klin Pneumol 1983; 37 (Suppl. 1) : 455-7.

3. Schabet M. Cerebral tuberculoma in pregnancy. Nervenarzt 1988; 59 (7) : 405-7.

4. Thomas ND. Tuberculosis. In : Harrison’s principles of internal medicine, New York, McGraw-Hill. 1991; 1 : 637.

 

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