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Isolated conus medullaris tuberculoma mimicking a tumour: a rare case report A 46-year-old man, residing in Tamil Nadu (India) had mid and low backache with progressive weakness of bilateral (B/L) lower limbs with bowel and bladder incontinence, difficulty in walking and impotence for 1 month. On examination, there was no spinal tenderness. Spinal movements were painfully restricted, neurology = spasticity in both lower limbs, power was grade 3 in B/L hips and knees, left ankle grade 2, right ankle grade 3, hypoesthesia below L3 B/L, reflexes B/L knees and ankle +++, right plantar Babinski +, left plantar was neutral. Magnetic resonance imaging showed intramedullary isointense mass lesion near the conus region at D11-D12 measuring 1.4 × 1.6 × 2.6 cm with moderate heterogeneous enhancement with hypoenhancing areas with perilesional oedema from D7 to L1 with expansion of the cord (Fig. 1). Surgical resection was performed through posterior midline approach (Fig. 2). D11-D12-L1 laminectomies with midline

durotomy and myelotomy were performed. The tumour was found to be adherent to the neural structures and subtotal excision was performed piecemeal and was sent for culture sensitivity and histopathological biopsy. On gross appearance, it was bluish gray friable, multi-lobulated mass. Aggregate mass collected was of size 2.5 × 2 × 1 cm. Histological sections showed fibrocollagenous tissue with dense chronic inflammatory cell infiltrate. Extensive caseous necrosis with multiple granulomas composed of epithelioid cells and multinucleated giant cells were seen (Fig. 3). Ziehl-Neelsen showed acid-fast bacilli. Follow-up at 3 months showed full neurological recovery with anti-tuberculous therapy.

Fig. 2. Intraoperative photograph: after durotomy and myelotomy of the spinal cord with arrow showing a greyish red mass which was adherent to the surrounding structures.

Fig. 1. Magnetic resonance imaging sagittal section of spine: showing intramedullary isointense mass lesion near the conus region at D11-D12 with perilesional oedema from D7 to L1 with expansion of the cord. Arrow shows the level at D12 vertebra.

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Fig. 3. Photomicrograph with 4× magnification of haematoxylin and eosin stain showing numerous granulomas. Arrow showing a granuloma.

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The first report of intramedullary tuberculoma was by Abercrombie in 1828.1 These are rare lesions affecting two out of 100 000 cases of systemic tuberculosis (TB) and two out of 1000 cases of central nervous system (CNS) TB.2 CNS TB affects 0.5–2% cases of systemic TB.3 Conus intramedullary lesions are an extremely rare presentation. Extradural form is the most common while arachnoiditis, intramedullary and intradural tuberculomas are uncommon presentation of spinal TB.4,5 This atypical form of TB can occur from the vertebrae or as a downward extension of intracranial tubercular meningitis and less commonly as tuberculous lesions primarily developing in spinal meninges.6,7 The neurological manifestations of spinal tuberculosis are most often secondary to the involvement of the bone but Mycobacterium tuberculosis can involve the neural and perineural tissues directly.8 Clinically, as well as radiologically, intramedullary tuberculomas may be difficult to differentiate from space occupying lesions such as primary and metastatic intramedullary spinal tumours and other chronic granulomatous diseases (sarcoidosis, brucellosis and histiocytosis).9 Hence, TB should be kept as a differential diagnosis in isolated lesions of the spinal cord.

References 1. Abercrombie J. Pathological and Practical Researches on Disease of the Brain and the Spinal Cord. Edinburg: Waugh and Innes, 1828; 371–2. 2. Citow JS, Ammirati M. Intramedullary tuberculoma of the spinal cord: case report. Neurosurgery 1994; 35: 327–30.

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3. Torii H, Takahashi T, Shimizu H, Watanabe M, Tominaga T. Intramedullary spinal tuberculoma: case report. Neurol. Med. Chir. (Tokyo) 2004; 44: 266–8. 4. Gupta RK, Kumar S. Central nervous system tuberculosis. Neuroimaging Clin. N. Am. 2011; 21: 795–814. 5. Hristea A, Constantinescu RV, Exergian F, Arama V, Besleaga M, Tanasescu R. Paraplegia due to nonosseous spinal tuberculosis: report of three cases and review of the literature. Int. J. Infect. Dis. 2008; 12: 425–9. 6. Sree Harsha CK, Shetty AP, Rajasekaran S. Intradural spinal tuberculosis in the absence of vertebral or meningeal tuberculosis: a case report. J. Orthop. Surg. (Hong Kong) 2006; 14: 71–5. 7. Poon TL, Ho WS, Pang KY, Wong CK. Tuberculous meningitis with spinal tuberculous arachnoiditis. Hong Kong Med. J. 2003; 9: 59–61. 8. Compton JS, Dorsch NW. Intradural extramedullary tuberculoma of the cervical spine. J. Neurosurg. 1984; 60: 200–3. 9. Kotil K, Guzel N. Primary intramedullary tuberculoma of the spinal cord mimicking to spinal cord tumor. J. Neurol. Sci (Turkish) 2006; 23: 63–7.

Lokesh Mohan Sharoff,* DNB (Ortho), D.Ortho Ranjith Unnikrishnan,* MS (Ortho), DNB (Ortho) Naeem Jagani,† DNB (Ortho), D.Ortho *Orthopaedic Surgery, Kerala Institute of Medical Sciences, Trivandrum, Kerala, India and †Orthopedic Surgery, Madras Institute of Orthopedics and Traumatology, Chennai, Tamil Nadu, India doi: 10.1111/ans.13069

© 2015 Royal Australasian College of Surgeons

Isolated conus medullaris tuberculoma mimicking a tumour: a rare case report.

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