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ARTICLE IN PRESS
doi:
10.25259/JNRP-2022-2-34

Falcine tuberculoma presenting with chronic headache – A rarity

Department of Neurology, NIMHANS, Bengaluru, Karnataka, India
Corresponding author: Girish Baburao Kulkarni, Department of Neurology, NIMHANS, Bengaluru, Karnataka, India. gbk5000@rediffmail.com
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How to cite this article: Taallapalli AV, Shivaram S, Kulanthaivelu K, Nashi S, Kulkarni GB. Falcine tuberculoma presenting with chronic headache – A rarity. J Neurosci Rural Pract, doi: 10.25259/JNRP-2022-2-34

A 28-year-old man presented to outpatient department in July 2019 with complaints of throbbing type of headache for the past 2 years, once in 2 months, with associated photophobia and phonophobia. Four months before presentation, headache increased in frequency and intensity. He required daily analgesics. He also had tinnitus and giddiness. No nausea, vomiting, cough, fever, and loss of weight. No focal deficits on examination. MRI [Figure 1] showed T2 hypointense, T1 hyperintense nodular enhancing pachymeningeal thickening along the falx cerebri. Furthermore, there was leptomeningeal enhancement along cingulate, marginal, and callosal sulci.

Figure 1:: (a) Axial T1 image shows hyperintense lesions. (b and c) Axial and coronal T2-weighted images reveal nodular T2 hypointense ill-defined lesions in the interhemispheric location. Axial FLAIR image (d) shows mild perilesional edema in the cingulate regions. Susceptibility weighted imaging (e) shows no blooming. Diffusion-weighted trace image (f) demonstrates no evidence of restriction. The post-contrast T1-weighted axial and coronal (g and h) images show nodular and plaque like enhancement in the interhemispheric/falcine lesions with contiguous extension of the nodular enhancing foci into the sulci.

This patient presented with chronic headache without other features of raised intracranial tension, with recent worsening of symptoms. Imaging shows features consistent with pachymeningeal and leptomeningeal thickening with enhancement which favor granulomatous inflammation rather than a tumor.

Computed tomography of chest was normal, hemoglobin − 14.3 g/dl, ESR – 9 m/h, HIV, VDRL – non-reactive, ANA profile, ANCA, Serum Brucella antibody – negative, CSF – normal, Cartridge-based Nucleic Acid Amplification Test – negative, CD4 – 866/mcl, Mantoux was negative.

Biopsy was deferred since patient did not consent and was started on empirical four drug anti-tubercular treatment without steroids from local hospital which was continued pending investigations. Headache reduced within 1 month. MRI repeated [Figure 2] in October, 2019 showed significant resolution and patient is continued on ATT and is on regular follow-up.

Figure 2:: Axial and coronal T2-weighted images (a and b) reveal nodular T2 hypointense decrease in the dimensions of ill-defined lesions in the interhemispheric location. Axial FLAIR image (c) shows an interval decrease in the mild perilesional edema in the cingulate regions. Post-contrast T1-weighted axial and coronal (d and e) images show marked interval reduction in extent and the dimensions of the nodularity in the interhemispheric location.

Falcine tuberculoma is a rare entity. Any patient with chronic headache with recent worsening needs urgent imaging.[1,2] Falcine lesion with pachymeningeal and leptomeningeal thickening with enhancement is clue for granulomatous inflammation rather than tumor.

Declaration of patient consent

The authors certify that they have obtained all the appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. , , , . Frontal lobe tuberculoma. Oxf Med Case Rep. 2016;2016:12-4.
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  2. , , , , . Tuberculous meningitis presenting as isolated interhemispheric exudates. J Med Imaging Radiat Oncol. 2010;54:129-33.
    [CrossRef] [PubMed] [Google Scholar]

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