Investig Magn Reson Imaging.  2015 Dec;19(4):231-236. 10.13104/imri.2015.19.4.231.

Tumor-like Presentation of Tubercular Brain Abscess: Case Report

Affiliations
  • 1Department of Radio-diagnosis, Patan Academy of Health Sciences, Patan, Nepal. kedibi@yahoo.com
  • 2Department of Radio-diagnosis, Tribhuvan University Teaching Hospital, Kathmandu, Nepal.
  • 3Department of Neurosurgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal.
  • 4Department of Pathology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal.
  • 5Department of Neurology, National Academy of Medical Sciences, Bir Hospital, Kathmandu, Nepal.

Abstract

A 17-year-old girl presented with complaints of headache and decreasing vision of one month's duration, without any history of fever, weight loss, or any evidence of an immuno-compromised state. Her neurological examination was normal, except for papilledema. Laboratory investigations were within normal limits, except for a slightly increased Erythrocyte Sedimentation Rate (ESR). Non-contrast computerized tomography of her head revealed complex mass in left frontal lobe with a concentric, slightly hyperdense, thickened wall, and moderate perilesional edema with mass effect. Differential diagnoses considered in this case were pilocytic astrocytoma, metastasis and abscess. Magnetic resonance imaging (MRI) obtained in 3.0 Tesla (3.0T) scanner revealed a lobulated outline cystic mass in the left frontal lobe with two concentric layers of T2 hypointense wall, with T2 hyperintensity between the concentric ring. Moderate perilesional edema and mass effect were seen. Post gadolinium study showed a markedly enhancing irregular wall with some enhancing nodular solid component. No restricted diffusion was seen in this mass in diffusion weighted imaging (DWI). Magnetic resonance spectroscopy (MRS) showed increased lactate and lipid peaks in the central part of this mass, although some areas at the wall and perilesional T2 hyperintensity showed an increased choline peak without significant decrease in N-acetylaspartate (NAA) level. Arterial spin labelling (ASL) and dynamic susceptibility contrast (DSC) enhanced perfusion study showed decrease in relative cerebral blood volume at this region. These features in MRI were suggestive of brain abscess. The patient underwent craniotomy with excision of a grayish nodular lesion. Abundant acid fast bacilli (AFB) in acid fast staining, and epithelioid cell granulomas, caseation necrosis and Langhans giant cells in histopathology, were conclusive of tubercular abscess. Tubercular brain abscess is a rare manifestation that simulates malignancy and cause diagnostic dilemma. MRI along with MRS and magnetic resonance perfusion studies, are powerful tools to differentiate lesions in such equivocal cases.

Keyword

Brain abscess; Magnetic resonance imaging; Diffusion weighted imaging; Magnetic resonance spectroscopy; Perfusion imaging

MeSH Terms

Abscess
Adolescent
Astrocytoma
Blood Sedimentation
Blood Volume
Brain Abscess*
Brain*
Choline
Craniotomy
Diagnosis, Differential
Diffusion
Edema
Epithelioid Cells
Female
Fever
Frontal Lobe
Gadolinium
Giant Cells, Langhans
Granuloma
Head
Headache
Humans
Lactic Acid
Magnetic Resonance Imaging
Magnetic Resonance Spectroscopy
Necrosis
Neoplasm Metastasis
Neurologic Examination
Papilledema
Perfusion
Perfusion Imaging
Weight Loss
Choline
Gadolinium
Lactic Acid

Figure

  • Fig. 1 (a) Non-contrast CT scan of head revealed an irregular cystic mass with concentric slightly thick wall in the left frontal lobe with moderate perilesional edema and mass effect. (b, c) T1 weighted axial (b) and T2 weighted axial (c) delineate lobulated outline mass in left frontal lobe in anterior aspect which displayed two concentric hypointense wall in T2 and iso-signal intensity in T1. Alternating hypointense areas were noted between the wall in T1 and high signal intensity in T2 weighted images. Moderate perilesional edema with mass effect also noted. (d) FLAIR axial showed two irregular concentric hypointense wall with in between and perilesional hyperintensity. (e, f) Post contrast T1 axial (e) and post contrast T1 sagittal (f) studies showed markedly enhancing two slightly irregular wall with some nodular solid enhancing component in the anterior aspect. (g, h) DWI - b1000 (g) and DWI - ADC map (h) show no restricted diffusion was seen within this mass in DWI. (i) ASL showed decreased rCBV at the lesion. (j) DSC perfusion study showed decreased rCBV in center. No increased rCBV seen in the region of walls.

  • Fig. 2 (a, b) MRS displayed increase in lactate and lipid peaks at the central part of the mass. Few areas at the periphery of the mass shows increased choline peak without significant decrease in NAA level.

  • Fig. 3 (a) Excised organized capsulated mass of the lesion. (b) Histopathology showing discrete to confluent epithelioid cell granulomas with extensive caseation necrosis and Langhans giant cells.


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