Tubercle and Lung Disease (1995)76, 271-272 © 1995Pearson Professional Ltd Tubercleand LungDisease Multiple intracranial tuberculomas mimicking brain metastases M. R. E1-Sonbaty, N. U.A.M.A. Abdul-Ghaffar, A. A. Marafy Adan Hospital, Kuwait S U M M A R Y. A 50-year-old woman was admitted to our hospital with upper gastro-intestinal tract (GIT) bleeding, and complaining of severe headache and recurrent generalized tonic clonic seizures for the last year. Physical examination showed no focal neurological deficits. The patient was diagnosed with multiple brain metastases with occult primary depending on computerised tomography (CT) findings. Biopsy of enlarged left axillary lymph nodes showed caseating tuberculoid lymphadenitis compatible with tuberculosis. Intracranial lesions resolved completely on antituberculosis treatment. R/~ S U M/~. Un femme fig~e de 50 ans a ~t~ admise h l'h6pital souffrant d'une h~morragie du tractus gastrointestinal (GIT) sup~rieur. Elle se plaignait de c~phai~es s~v~res et de crises cloniques et toniques g~n~ralis~es et r~guli~res depuis un an. Une examen physique n'a montr~ aucune d~ficience neurologique en foyer. Le diagnostic chez cette malade a ~t~ celui de m~tastases c~r~brales multiples de foyer primaire inconnu, en fonction des donn~es scannographiques. Une biopsie des ganglions lymphatiques axillaires de volume augmentS, h gauche, a montr~ une lymphad~ulte tuberculo'ide cas~ense compatible avec une tuberculose. Les l~sions intracrfiniennes se sont r~solues enti~rement grfice hun traitement antituberculeux. R E S U M E N. Una mujer de 50 afios de edad fue hospitalizada en nuestro servicio por una hemorragia del tracto gastrointestinal (GIT) superior. Se quejaba de cefaleas intensas y de crisis t6nico.cl6nicas generalizadas desde hacla un afio. El examen fisico no demostraba alteraciones neurol6gicas focales. Se hizo el diagn6stico de metastasis cerebrales mdltiples con tumor primario desconocido dependiente de los hailazgos de la tomografia computarizada. La biopsia de ganglios linf~iticos axilares izquierdos aumentados de volumen mostr6 una linfadenitis tuberculoidea caseosa, compatible con una tuberculosis. Las lesiones intracraneanas se resolvieron completamente despu~s de un tratamiento antituberculoso. A 50-year-old woman was admitted with upper gastrointestinal (GIT) bleeding due to erosive gastritis (as shown by upper GIT endoscopy). Apart from the bleeding, which stopped with treatment, the patient had hypothyroidism on replacement therapy, and gave a history of recurrent generalized seizures and attacks of severe headache for several months before admission. She had no fever, cough or loss of weight. She was receiving phenytoin to control her seizures and analgesics for the headache. Physical examination revealed a fair general condition. There were no focal neurological deficits and fundi were normal. Enlarged left axillary lymph nodes were found and taken for biopsy. The patient had been seen previously in two different general hospitals by two different teams of physicians and neurosurgeons. Exhaustive investigations were done including computerized tomography (CT) of the brain (performed twice). CT was reported on the two occasions as brain meta- stases, and the patient was managed accordingly. CT was repeated in our hospital for the third time, and showed multiple hypodense lesions in both cerebral hemispheres associated with brain oedema. Lesions were enhancing with contrast, and many of them showed typical ring enhancement (target sign). Ten lesions were demonstrated in the left hemisphere with one in the left internal capsule, and seven were found in the right hemisphere (Figs 1 and 2). Magnetic resonance could not be done. Chest X-ray film showed right apical lung shadow. Sputum for acid-fast bacilli (AFB) was repeatedly negative. Screening for human immunodeficiency virus (HIV) using enzyme-linked immunosorbent assay was negative. Lymph node biopsy showed caseating tuberculoid lymphadenitis compatible with tuberculosis. The patient was started on rifampicin 600 mg daily, isoniazid (INH) 300 mg daily, ethambutol 800 mg twice daily, pyrazinamide 500 mg tds, and pyridoxin 50 mg daily, on 14 February 93. On 13 April the patient had five-fold elevation of liver enzymes (alanine transaminase, aspartate transaminase and lactic dehydro- Correspondence to: Dr Naser U.A.M.A. Abdul-Ghaffar, PO Box 46468, Fehahil 64015, Kuwait. 271 272 Tubercle and Lung Disease A second follow-up cranial CT on 2 August 1993, showed almost complete resolution of the intracranial lesions. DISCUSSION Although CT has greatly improved diagnostic accuracy for intracranial tuberculoma, and provided valuable information about its response to chemotherapy, ',2 we should keep in mind that neoplastic, fungal, and parasitic disease may cause similar changes on CT. 3 CT scanning has been reported in some series as misdiagnosing tuberculoma for intracranial neoplasia in as many as 80% of cases. 4 In this case CT was repeated 3 times, with and without contrast, and each time it was reported as brain metastases. This highlights the nonspecific nature of CT in the diagnosis of intracranial tuberculomas. Target sign claimed to be specific 2 was found in some lesions. Multiple intracranial tuberculomas are well documented, and extensive lesions are well described, "--6 but such a number of intracranial tuberculomas (17) in one patient was not reported by others. Our patient presented with recurrent seizures and headache which is quite common, but the diagnosis was made only when tuberculosis was found elsewhere. The patient had no focal neurological deficits, despite the extensive brain involvement. Her response to treatment was dramatic: in 3 months there was marked resolution of the intracranial lesions and almost complete resolution in 6 months. This type of dramatic response has been observed by others with recent antituberculosis chemotherapy regimens. 7 References Figures 1 and 2--CT scan with contrast showing 10 intracranial tubercles in the right frontal lobe, with one in the right internal capsule, and 7 tubercles in the left frontal lobe. genase) and serum bilirubin was 112 gMol/L. Screening for hepatitis-B antigens and antibodies and hepatitis-C antibodies was negative. INH blood level could not be done in our laboratory. Two weeks after stopping rifampicin and INH, liver enzymes and serum bilirubin were back to normal. 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