This document summarizes a case presentation at a regional CRC meeting in Gondar, Ethiopia in December 2023. The case involves a 13-year-old male child who presented with a 5 month history of progressive left side body weakness and intermittent headache. On examination, he had 4/5 strength on the left upper and lower extremities with exaggerated reflexes on the left side. Imaging showed a large ring-enhancing mass in the right frontal lobe. Given his contact history with a father with drug-resistant TB, he was diagnosed with CNS tuberculoma and started on a longer oral treatment regimen of second-line anti-TB drugs. The discussion covers clinical features, diagnosis, treatment and management of C

1. RegionalCRC meeting
Gondar, Ethiopia
Decembr,2023
Tilahun Nega (MD, UoG CSH TB focal, member-R & National CRC)

2. RegionalCRC
selected
Case
presentation
Case one

3. Case 0ne
History
 A 13-year-old male child from
Gabila, West Gondar presented
with a five (05) months history of
progressive left side body
weakness,with associated
intermittent headache
 He described his headache as
global, intermittent, throbbing in
nature, non-radiating, with no
relieving factors.
 He had been complaining of the
headache since a year back
 but no ABM, bowel or bladder
incontinence.
 His symptoms initially started with
limping and later progressing to
loss of balance while walking
 .
Conti…
 He also had paresthesia and
numbness before the start of
body weakness.
Over the past 5 months, he had
loss of appetite drenching night
sweat, significant unquantified
weight loss
 Concomitantly, He was also
unable to grasp with his left hand
since 05 months back
 His is living with his father who
had been diagnosed with RR-
Pulmonary TB and on treatment
with second line Anti-TB
drugs(LTR)
 Otherwise no history of cough,
chest pain nor fever

4. Case
Physical examination
 G/A: chronically sick looking
 V/S: stable
 HEENT: NIS & PC
 LGS: No LAP
 Chest : clear and resonant
 CVS: flat JVP, S1 &S2 well heard
, No Mr
 Abd: Symmetric & full ,No
organomegally
 MSS: no edema or deformity
Conti….
 CNS:COTPP, pupils are equal and
reactive bilaterally
 CN exam: all are intact, no extra ocular
eye movement abnormality
 Motor:4/5 on the LU and LL extremities
 Tone: normotonic bilaterally
 Reflex: exaggerated on the left side, 4/4
Lt knee, anke & biceps
 Plantar reflex: no response on the left
 Sensory:There is no specific sensory level
 Meningeal sign: Negative

5. Strength
extremity Hip flexion
extension
Knee flexion
extension
Anke flexion
extension
Elbow flexion
extension
Left 4/5 4/5 4/5 4/5
Right 5/5 5/5 5/5 5/5

6. Investigation
 CBC :Hgb=12.7
Hct=46.3%
 Plt=222*103
• RBS=123
• LFT= all normal.
• RFT=all normal
• Gxpert= no MTB
detected
• CXR=Bilateral hilar and
mediassinal LAP
 Chest CT:
 There is a multi-lobulated large right high
frontal subcortical white matter well defined
mass lesion measuring 4*3.5*3.7 cm.
 it is also hyodense on pre-contrast study with
central foci of calcification & has a thin smooth
complete ring enhancement on post contrast
study.
 there is significant surrounding vasogenic
edema causing mass effect with midline shift
of 7mm
 No uncal herination seen.
 Impression:
Rt frontal white matter large ring enhancing
mass likely tuberculoma r/oTb brain abscess

7. Patient
management
 Management:
 Considering his contact history to DR-TB index case ( his father) and
clinical and imaging findings, CNS tuberculoma was high on the DDx
 .we started management with fully oral longer treatment regimen
 Bdq-Lzd-Lfx-Cfz-Cs-Vit B6 (on April 22,2023)
Currently showing good response & on follow-up

8. Discussion
 CNS-TB presents clinically as TB meningitis, spinal TB arachnoiditis,
abscesses, and rarely as tuberculomas.
 Pediatric patients infected withTB rarely (2%) present with tuberculomas
 Because of its rarity, non-specific presentation, and radiological findings,
early diagnosis is still a clinical challenge
 TB infection occurs through inhalation of a droplet containing bacilli, which
leads to the deposition in the lung alveoli and activation ofT-helper cells.
 T-helper cell immune-mediated response leads to the formation of
granuloma and primary pulmonaryTB
 Prior to the containment of the infection, some bacilli are filtered into the
lymphatic system, which leads to hematogenous dissemination to the
distant parts of the body, which are highly oxygenated like the brain.
 Host immunity, the virulence of TB strain, and oxygenation plays a vital role
in clinical features ofTB
 Meegada S, Gyamfi R, MuppidiV, et al. (March 12, 2020)

9. Discussion
conti…
CNS-TB can present with
headache,
fever,
seizures,
hemiplegia,
papilledema, or
occasionally with signs of raised intracranial pressure and non-specific
features like
 fatigue,
weight loss,
lack of appetite
Our patient presented with headache, progressive body weakness , ,
paresthesia and numbness.
Clinical manifestations usually correlate to the location of tuberculoma
in the brain. Meningeal signs and symptoms of systemic illness are not
commonly observed.

10. Conti…
 Diagnostic evaluation of CNS-TB starts with proper history taking
including contact history, physical exam with thorough neurological
examination, sputum acid-fast bacilli (AFB) stain, culture and
sensitivity, chest X-ray, CT scan of the brain/chest, and MRI of the
brain.
 Definitive Diagnosis of CNS is usually made by demonstration of TB
bacilli in the biopsied tissue.

11. Treatment
 Treatment is started based on strong clinical suspicion and should not be
delayed to reduce morbidity and mortality
 The treatment regimens should be evidence based & according to latest
WHO recommendations.
 outlined and published in the United States Centers for Disease Control and
Prevention (CDC) . CNS TB is usually treated with drugs having good BB
barrier penetration.
 Treatment must be tailored to the culture and sensitivity of the TB bacilli and
drug resistance.
 Adjunctive steroid therapy is recommended in patients with TB meningitis
(suspected or confirmed), basilar enhancement on radiographic imaging,
presence of intracranial tuberculomas (like our patient),CSF protein greater
than 500 mg/dL, & worsening of clinical signs after being onAnti-TB therapy
:

12. Conclusion
 TB patients with elevated ICP or neurological deficits but with no
meningeal signs or systemic symptoms, it is important to rule out
CNS tuberculoma.
 Considering the substantial morbidity and mortality rate of CNS-TB,
early identification and treatment are crucial
 CNS tuberculoma should be considered in the differential diagnosis of
ring-enhancing lesions on brain imaging in patients with risk factors
 Steroids and a conventional anti-TB regimen are used as treatment.
 Rarely is surgical resection required.

13. Reference
1) Nelson principles of pediatrics 20th edition
2) Harrison principles of internal medicine 21st edition
3) Meegada S, Gyamfi R, MuppidiV, et al. (March 12, 2020)
4) Cherian A, Thomas SV: Central nervous system tuberculosis. Afr
Health Sci. 2011, 11:116-27
5) https://www.who.int/tb/publications/global_report/tb19_Exec_
Sum_12Nov2019.pdf?ua=1.

14. Thank you!.