Tuberculoma mimicking postoperative VP shunt seeding of craniopharyngioma: A rare case report

Background: Tuberculosis (TB) is still a big problem in developing and TB endemic countries such as Indonesia. The most common manifestations of TB in the central nervous system are tuberculous meningitis and tuberculoma. In developing and TB endemic countries, tuberculomas account for 33% of intracranial space-occupying lesions. Isolated tuberculoma without systemic TB is rarely seen. On physical and radiological examination, tuberculoma often gives an atypical appearance. From imaging, tuberculoma often mimics another intracranial tumor. Oftentimes the accurate diagnosis can only be made after postoperative histopathological and microbiology examination. Case Description: An 11-year-old, Indonesian girl has been complaining persistent headache in the past 3 years. The patient had a history of surgical excision of craniopharyngioma 8 years ago, and placement of ventriculoperitoneal shunt due to postoperative hydrocephalus. Patient was immunocompetent with no sign of systemic TB nor tuberculous meningitis. Brain magnetic resonance imaging (MRI) revealed a 4 × 2.3 × 2.1 cm mass surrounding the ventricular drain which was attached in the anterior horn of the right lateral ventricle to the right frontal cortex. From dynamic susceptibility contrast MRI perfusion and MR Spectroscopy suggested a process of seeding metastases surrounding the ventricular drain. Postoperative histopathological examination results were consistent with tuberculoma. Conclusion: Tuberculoma should always be considered as one of the differential diagnoses along with primary and secondary intracranial neoplasm, particularly in developing and TB endemic countries, and inpatient with immunocompromised state.