Abstract
Intracranial tuberculoma is an important manifestation of pediatric central nervous system tuberculosis, especially in endemic regions. While seizures and signs of raised intracranial pressure are common presenting features, isolated focal neurological deficits without systemic or meningeal symptoms are rare, resulting in diagnostic delay. We report an unusual case of thalamic tuberculoma presenting primarily with gait disturbance in a young child. A 2-year-old boy from Karachi, Pakistan, presented with inability to walk independently at 20 months age. On neurological examination, he had decreased power involving left side of body. MRI of the brain showed a ring-enhancing lesion in the right thalamus extending into the midbrain with surrounding vasogenic edema. Magnetic resonance spectroscopy (MRS) showed a lipid/lactate peak, which supported an infectious granulomatous etiology; a presumptive diagnosis of tuberculoma was made based on imaging findings and household TB exposure. Although intracranial tuberculoma does not always present with systemic manifestations of tuberculosis in children, as observed in the present study, it is also a challenging disease to diagnose in young children due to the atypical presentation. Neuroimaging: Early diagnosis is possible. For deep-seated lesions where operative therapy and surgical treatment are highly risky, conservative management is often effective with anti-tuberculous therapy and adjunctive corticosteroids. Early physiotherapy to achieve functional recovery is very important. The case illustrates the need for consideration of intracranial tuberculoma in an individual neurological impairment case, considering children with isolated neurological deficits, when systemic forms of tuberculosis do not develop, even in the absence of evidence of systemic tuberculosis symptoms and history of direct exposure. Prompt imaging, early diagnosis, and treatment with anti-tuberculous therapy may lead to good outcomes.