Intramedullary Tuberculoma of the Spinal Cord Calvin H. Norman, Jr., MD, Andresito B. Pacis, MD Brooklyn, New York
In the differential diagnosis of intramedullary masses or tumors of the spinal cord, tuberculoma is an often overlooked possibility. Although rare, this entity should be considered in the differential gamut of spinal cord lesions even in the presence of a normal chest x-ray. In the differential diagnosis of intramedullary lesions of the spinal cord noted on myelographic examination, Reeder and Felson' indicate the most common etiological agents are glioma, syringomyelia, and hydromyelia. Uncommonly, such etiological agents as dermoids, hematomas, lipomas, melanomas, metastatic lesions, granulomas, and vascular malformations may produce the typical radiographic findings. Epstein,2 in his excellent review of spinal cord mass lesions, refers to only a single case of intramedullary spinal cord tuberculoma. Lin,3 in his review of the literature, refers to 16 previously reported cases of intramedullary tuberculoma, to which he added one of his own. Although this entity has been rarely reported in the world literature, mainly in India, only two cases have been reported of isolated intramedullary tuberculoma with no signs of a tuberculous disease foci in the lungs. The case presented is, to the best of the authors' knowledge, the first reported case of intramedullary tuberculoma of the spinal cord without a primary focus in the lung, in a patient from a country with a highly developed health system such as the United States. It is only the third reported case in the English medical literature.
Discussion and Review of the Literature A review of the literature indicates that as early as 1828, the so-called From the Department of Radiology, St. Mary's Hospital, Catholic Medical Center of Brooklyn and Queens, Brooklyn, NY. Requests for reprints should be addressed to Dr. Calvin H. Norman, Jr., Director, Department of Radiology, St. Mary's Hospital, 1298 St. Marks Avenue, Brooklyn, NY 11213.
"tubercules" of the cord and its lining membranes were already a familiar occurrence, as noted in the early writings of Abercrombie.4 The first description of what probably was a spinal cord tuberculoma, however, was attributed to E.R.A. Serre of Paris, in 1830, although this was disputed by Jenkins and Hill5 as one of an intradural tuberculoma. In Dastur' s excellent review and summary of their tuberculoma series, 260 cases were in the brain and six were in the cord. Of the 74 tuberculous paraplegias in this group, 44 were extradural, four were subdural, four combined subdural-extradural, and six were intramedullary.6 Arseni and Samitca7 had five spinal cord tuberculomas in their series of 206 central nervous systemn tuberculomas. Cabral in Sri Lanka had 51 cases of brain tuberculoma within a ten-year period with no case in the spinal cord. Kocen and Parsons8 had one report of a Ceylonese living in London with an intramedullary tuberculoma of the spinal cord. Balaparameswara, Rao,9 and Dinakar10 reported 13 cases of tuberculoma of the spinal cord of which one was intramedullary. Mathai and Chandy had two cases in the spinal cord compared with 143 intracranial granulomas. Webster1" reported one spinal cord tuberculoma in 7,000 autopsies contrasted with 18 cerebral tuberculomas in the same autopsy series. Johnson et al12 added two cases to seven cases already reported in the literature up to 1962. Jennings13 found only one among 5,344 patients with pulmonary tuberculosis. Tung Hui Lin3 has reported one case of intramedullary tuberculoma which was removed successfully. To date, as far as can be determined since 1922,14 there are 105 cases of intramedullary tuberculoma of the spi-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 3, 1979
nal cord reported in the world literature. All cases of intramedullary tuberculoma of the spinal cord reported since 1967 have been outside the United States. Of these cases reported, 88 specimens were removed postmortem while 17 were removed surgically. Of the 17 surgically removed, eight were reported to have successful results.'5 Most reported cases of intramedullary tuberculomna had pulmonary tuberculous foci prior to the onset of symptoms, although in the cases of Chandrasoma'6 and Bertrand et al,'7 the patients' general health was excellent and only the intraspinal tuberculoma was the detectable manifestation of tuberculosis. Jennings'3 found one tuberculoma of the spinal cord among 5,344 patients with pulmonary tuberculosis. All the patients with spinal cord involvement did not have Potts disease of the vertebrae.
Case Report A 54-year-old black female, who was born in Washington, DC, entered the hospital with complaints of generalized feeling of lightness throughout the body and itching of the left hand, followed by numbness and soreness. The symptoms began three months prior to her present hospital admission and progressed to stiffness of the left upper extremity with coldness and numbness. There was a past history of a "sinus operation" at a young age, umbilical herniography, and bilateral tubal ligation many years prior to her recent hospitalization. Family history was negative. Her physicial examination was normal except for obesity and peripheral neuropathy, consisting of sensory deficits from areas distal to the iliac crest and below the wrist. Impaired position sense of fingers and right toe was noted. Laboratory findings were all within the normal range. The chest x-ray was normal with no evidence of lung abnormalities of any kind. Specifically, 231
Sections revealed acid-fast bacilli (Figure 2). Following laminectomy and excision of the lesion, the patient was placed on ampicillin, streptomycin, and ethambutol and showed considerable improvement in her condition on discharge. One year later on follow-up, the patient was found to have continued weakness of the extremities, especially the hands, and a somewhat spastic gait. She was continued on physiotherapy.
Comment The paucity of reported cases of tuberculosis of the spinal cord in the American literature, plus the relatively rare incidence of sole intramedullary involvement of the spinal cord of this disease entity, has prompted the authors to report this case with the aim of adding to the literature and increasing the awareness that although this particular site may be rare, one must keep tuberculoma in i!i'%pli mind in the differential gamut of benign -Rx- l-s~ ~levels Figure 1. Myelogram showing diffuse widening of the cervical spinal cord, ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ C2 to C6. and malignant tumors of the spinal cord. Literature Cited 1. Reeder MM, Felson B: Gamuts in
Radiology, tape C-24. Cincinnati, Audiovisual
r~~~~~~~~~~~~~~~~~~~~~~~~~~~.
4~~~~~~
Figure 2. Photomicrograph showing granulomatous inflammation. Note the multinucleated giant cell of Langhans type on the left. N
no evidence of tuberculosis was found. Myelogram revealed diffuse widening of the spinal cord in the cervical region from the level of C2 to C6. An intramedullary tumor was suspected (Figure 1). On surgery, a firm infiltrating 232
intramedullary tumor mass, extending from C2 to C6, was found involving the spinal cord. Pathological report of the resected specimen showed evidence of chronic granulomatous inflammation with giant cells and areas of caseating necrosis.
Radiolgy 1975 2. Epstein BS: Spinal cord mass lesions. Radiol Clin North Am 4:185-202, 1966 3. Lin TH: Intramedullary tuberculoma of the spinal cord. J Neurosurg 17:497-499, 1960 4. Abercrombie J: Pathological and Practical Researches on Disease of the Brain and the Spinal Cord. Edinburgh, Waugh and Innes, 1828, pp 371-372 5. Jenkins RB, Hill C: Intradural spinal tuberculoma with genito-urinary symptoms. Arch Neurol 8:530-533, 1963 6. Dastur HM: A tuberculoma review with some personal experiences: II. Spinal cord and its coverings. Neurol India 20(3):127-131, 1972 7. Arseni C, Samitca DC: Intraspinal tuberculous granuloma. Brain 83:285-292, 1960 8. Kocen RS, Parsons M: Neurologic complications of tuberculosis-Some unusual manifestations. Q J Med 39:17-20, 1960 9. Rao BS, Dinakar I: Intramedullary tuberculoma of the spinal cord (case report). Indian J Med Sci 24(10):647-649, 1970 10. Dinakar I, Rao BS: Intramedullary tumors of the spinal cord. Indian J Cancer 8(4):292-296, 1971 11. Webster R: Pathological reports from the children's hospital, Melbourne. Aust Med J 1:1061-1064, 1938 12. Johnston JDH, Ashbell TS, Rosonoff HI: Isolated intraspinal: Extradural tuberculoma. N Eng J Med 266:703-705, 1962 13. Jennings FL: Tuberculoma of the spinal cord. Ann Int Med 7:1240-1243, 1934 14. Thalheimer W, Hassin GB: Clinicopathologic notes on solitary tuberole of the spinal cord. J Nerv Ment Dis 55:161-193. 1922 15. Natarajan M, Vedachalam SP, Ramamurthi B: Intramedullary tuberculoma of the spinal cord. Indian J Surg 24:727, 1962 16. Chandrasoma PT: Intramedullary cord tuberculoma resembling glioma. Neurol India 24030:1i64-166, 1976 17. Bertrand I, Guillaume JM, Samson M, et al: Tuberculome intramedullaire dorsal. Revue Neuroligique 98:51 -54, 1958
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 3, 1979
In the differential diagnosis of intramedullary masses or tumors of the spinal cord, tuberculoma is an often overlooked possibility. Although rare, this entity should be considered in the differential gamut of spinal cord lesions even in the presence of a normal chest x-ray. In the differential diagnosis of intramedullary lesions of the spinal cord noted on myelographic examination, Reeder and Felson' indicate the most common etiological agents are glioma, syringomyelia, and hydromyelia. Uncommonly, such etiological agents as dermoids, hematomas, lipomas, melanomas, metastatic lesions, granulomas, and vascular malformations may produce the typical radiographic findings. Epstein,2 in his excellent review of spinal cord mass lesions, refers to only a single case of intramedullary spinal cord tuberculoma. Lin,3 in his review of the literature, refers to 16 previously reported cases of intramedullary tuberculoma, to which he added one of his own. Although this entity has been rarely reported in the world literature, mainly in India, only two cases have been reported of isolated intramedullary tuberculoma with no signs of a tuberculous disease foci in the lungs. The case presented is, to the best of the authors' knowledge, the first reported case of intramedullary tuberculoma of the spinal cord without a primary focus in the lung, in a patient from a country with a highly developed health system such as the United States. It is only the third reported case in the English medical literature.
Discussion and Review of the Literature A review of the literature indicates that as early as 1828, the so-called From the Department of Radiology, St. Mary's Hospital, Catholic Medical Center of Brooklyn and Queens, Brooklyn, NY. Requests for reprints should be addressed to Dr. Calvin H. Norman, Jr., Director, Department of Radiology, St. Mary's Hospital, 1298 St. Marks Avenue, Brooklyn, NY 11213.
"tubercules" of the cord and its lining membranes were already a familiar occurrence, as noted in the early writings of Abercrombie.4 The first description of what probably was a spinal cord tuberculoma, however, was attributed to E.R.A. Serre of Paris, in 1830, although this was disputed by Jenkins and Hill5 as one of an intradural tuberculoma. In Dastur' s excellent review and summary of their tuberculoma series, 260 cases were in the brain and six were in the cord. Of the 74 tuberculous paraplegias in this group, 44 were extradural, four were subdural, four combined subdural-extradural, and six were intramedullary.6 Arseni and Samitca7 had five spinal cord tuberculomas in their series of 206 central nervous systemn tuberculomas. Cabral in Sri Lanka had 51 cases of brain tuberculoma within a ten-year period with no case in the spinal cord. Kocen and Parsons8 had one report of a Ceylonese living in London with an intramedullary tuberculoma of the spinal cord. Balaparameswara, Rao,9 and Dinakar10 reported 13 cases of tuberculoma of the spinal cord of which one was intramedullary. Mathai and Chandy had two cases in the spinal cord compared with 143 intracranial granulomas. Webster1" reported one spinal cord tuberculoma in 7,000 autopsies contrasted with 18 cerebral tuberculomas in the same autopsy series. Johnson et al12 added two cases to seven cases already reported in the literature up to 1962. Jennings13 found only one among 5,344 patients with pulmonary tuberculosis. Tung Hui Lin3 has reported one case of intramedullary tuberculoma which was removed successfully. To date, as far as can be determined since 1922,14 there are 105 cases of intramedullary tuberculoma of the spi-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 3, 1979
nal cord reported in the world literature. All cases of intramedullary tuberculoma of the spinal cord reported since 1967 have been outside the United States. Of these cases reported, 88 specimens were removed postmortem while 17 were removed surgically. Of the 17 surgically removed, eight were reported to have successful results.'5 Most reported cases of intramedullary tuberculomna had pulmonary tuberculous foci prior to the onset of symptoms, although in the cases of Chandrasoma'6 and Bertrand et al,'7 the patients' general health was excellent and only the intraspinal tuberculoma was the detectable manifestation of tuberculosis. Jennings'3 found one tuberculoma of the spinal cord among 5,344 patients with pulmonary tuberculosis. All the patients with spinal cord involvement did not have Potts disease of the vertebrae.
Case Report A 54-year-old black female, who was born in Washington, DC, entered the hospital with complaints of generalized feeling of lightness throughout the body and itching of the left hand, followed by numbness and soreness. The symptoms began three months prior to her present hospital admission and progressed to stiffness of the left upper extremity with coldness and numbness. There was a past history of a "sinus operation" at a young age, umbilical herniography, and bilateral tubal ligation many years prior to her recent hospitalization. Family history was negative. Her physicial examination was normal except for obesity and peripheral neuropathy, consisting of sensory deficits from areas distal to the iliac crest and below the wrist. Impaired position sense of fingers and right toe was noted. Laboratory findings were all within the normal range. The chest x-ray was normal with no evidence of lung abnormalities of any kind. Specifically, 231
Sections revealed acid-fast bacilli (Figure 2). Following laminectomy and excision of the lesion, the patient was placed on ampicillin, streptomycin, and ethambutol and showed considerable improvement in her condition on discharge. One year later on follow-up, the patient was found to have continued weakness of the extremities, especially the hands, and a somewhat spastic gait. She was continued on physiotherapy.
Comment The paucity of reported cases of tuberculosis of the spinal cord in the American literature, plus the relatively rare incidence of sole intramedullary involvement of the spinal cord of this disease entity, has prompted the authors to report this case with the aim of adding to the literature and increasing the awareness that although this particular site may be rare, one must keep tuberculoma in i!i'%pli mind in the differential gamut of benign -Rx- l-s~ ~levels Figure 1. Myelogram showing diffuse widening of the cervical spinal cord, ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ C2 to C6. and malignant tumors of the spinal cord. Literature Cited 1. Reeder MM, Felson B: Gamuts in
Radiology, tape C-24. Cincinnati, Audiovisual
r~~~~~~~~~~~~~~~~~~~~~~~~~~~.
4~~~~~~
Figure 2. Photomicrograph showing granulomatous inflammation. Note the multinucleated giant cell of Langhans type on the left. N
no evidence of tuberculosis was found. Myelogram revealed diffuse widening of the spinal cord in the cervical region from the level of C2 to C6. An intramedullary tumor was suspected (Figure 1). On surgery, a firm infiltrating 232
intramedullary tumor mass, extending from C2 to C6, was found involving the spinal cord. Pathological report of the resected specimen showed evidence of chronic granulomatous inflammation with giant cells and areas of caseating necrosis.
Radiolgy 1975 2. Epstein BS: Spinal cord mass lesions. Radiol Clin North Am 4:185-202, 1966 3. Lin TH: Intramedullary tuberculoma of the spinal cord. J Neurosurg 17:497-499, 1960 4. Abercrombie J: Pathological and Practical Researches on Disease of the Brain and the Spinal Cord. Edinburgh, Waugh and Innes, 1828, pp 371-372 5. Jenkins RB, Hill C: Intradural spinal tuberculoma with genito-urinary symptoms. Arch Neurol 8:530-533, 1963 6. Dastur HM: A tuberculoma review with some personal experiences: II. Spinal cord and its coverings. Neurol India 20(3):127-131, 1972 7. Arseni C, Samitca DC: Intraspinal tuberculous granuloma. Brain 83:285-292, 1960 8. Kocen RS, Parsons M: Neurologic complications of tuberculosis-Some unusual manifestations. Q J Med 39:17-20, 1960 9. Rao BS, Dinakar I: Intramedullary tuberculoma of the spinal cord (case report). Indian J Med Sci 24(10):647-649, 1970 10. Dinakar I, Rao BS: Intramedullary tumors of the spinal cord. Indian J Cancer 8(4):292-296, 1971 11. Webster R: Pathological reports from the children's hospital, Melbourne. Aust Med J 1:1061-1064, 1938 12. Johnston JDH, Ashbell TS, Rosonoff HI: Isolated intraspinal: Extradural tuberculoma. N Eng J Med 266:703-705, 1962 13. Jennings FL: Tuberculoma of the spinal cord. Ann Int Med 7:1240-1243, 1934 14. Thalheimer W, Hassin GB: Clinicopathologic notes on solitary tuberole of the spinal cord. J Nerv Ment Dis 55:161-193. 1922 15. Natarajan M, Vedachalam SP, Ramamurthi B: Intramedullary tuberculoma of the spinal cord. Indian J Surg 24:727, 1962 16. Chandrasoma PT: Intramedullary cord tuberculoma resembling glioma. Neurol India 24030:1i64-166, 1976 17. Bertrand I, Guillaume JM, Samson M, et al: Tuberculome intramedullaire dorsal. Revue Neuroligique 98:51 -54, 1958
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 3, 1979
