AlBathi Abdullah K, Al-Mutairi Abdullah A, Alqurashi Rewaa N, Alsaleh Mujtaba E, AlQurayyan Rayyan A
Department of Radiology, King Fahad Medical City, Riyadh, SAU.
Department of Adult Infectious Diseases, King Fahad Medical City, Riyadh, SAU.
Cureus. 2025 Aug 15;17(8):e90155. doi: 10.7759/cureus.90155. eCollection 2025 Aug.
Intracranial tuberculomas are rare granulomatous infections that can closely mimic high-grade gliomas on imaging, posing significant diagnostic challenges, particularly in non-endemic regions. We present a case of a 54-year-old immunocompetent male patient with a background of schizophrenia who presented with acute right-sided weakness, left facial droop, and slurred speech. Initial imaging revealed a large left thalamic mass with midline shift and uncal herniation, concerning for a high-grade glioma. Magnetic resonance imaging (MRI) findings demonstrated a heterogeneous thalamic lesion with extensive surrounding white matter changes, elevated choline peak, and decreased N-acetylaspartic acid (NAA) on magnetic resonance (MR) spectroscopy, further supporting the preliminary diagnosis of glioma. However, systemic imaging revealed mediastinal lymphadenopathy and hepatic lesions suggestive of a lymphoproliferative or infectious process. Stereotactic biopsy of the lesion revealed chronic necrotizing granulomatous inflammation without evidence of neoplasia. Although acid-fast bacilli culture and mycobacterial polymerase chain reaction (PCR) were pending, empirical antituberculous therapy was initiated based on histopathology findings. Subsequent follow-up imaging showed marked reduction and near-complete resolution of the lesion, confirming the diagnosis of intracranial tuberculoma. This case highlights the radiologic and clinical overlap between intracranial tuberculomas and high-grade gliomas. Despite advanced imaging modalities such as MR spectroscopy and perfusion studies, differentiation remains challenging. Biopsy remains the gold standard for definitive diagnosis. Awareness of atypical presentations and careful integration of clinical, radiologic, and epidemiologic data are critical to avoid misdiagnosis and unnecessary neurosurgical interventions. Early initiation of antituberculous therapy can lead to excellent clinical and radiologic outcomes, as illustrated in this case.
颅内结核瘤是罕见的肉芽肿性感染，在影像学上可与高级别胶质瘤极为相似，带来重大诊断挑战，尤其是在非流行地区。我们报告一例54岁免疫功能正常的男性患者，有精神分裂症病史，表现为急性右侧肢体无力、左侧面部下垂和言语含糊不清。初始影像学检查发现左侧丘脑有一个大肿块，伴有中线移位和钩回疝，怀疑为高级别胶质瘤。磁共振成像（MRI）结果显示丘脑病变不均质，周围白质有广泛改变，磁共振波谱显示胆碱峰升高、N-乙酰天门冬氨酸（NAA）降低，进一步支持胶质瘤的初步诊断。然而，全身影像学检查发现纵隔淋巴结肿大和肝脏病变，提示存在淋巴增殖性或感染性病变。病变的立体定向活检显示为慢性坏死性肉芽肿性炎症，无肿瘤形成证据。尽管抗酸杆菌培养和分枝杆菌聚合酶链反应（PCR）结果待定，但根据组织病理学结果开始了经验性抗结核治疗。随后的随访影像学检查显示病变明显缩小且几乎完全消退，确诊为颅内结核瘤。该病例突出了颅内结核瘤与高级别胶质瘤在影像学和临床方面的重叠。尽管有磁共振波谱和灌注研究等先进的影像学检查方法，但鉴别诊断仍具有挑战性。活检仍然是明确诊断的金标准。认识到非典型表现并仔细整合临床、影像学和流行病学数据对于避免误诊和不必要的神经外科干预至关重要。如本病例所示，早期开始抗结核治疗可带来良好的临床和影像学结果。
