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Show PHOTO ESSAY Irreversible Blindness Due to Multiple Tuberculomas in the Suprasellar Cistern Kumudini Sharma, MD, Sunil Pradhan, MD, DM, Atul Varma, MS, and Bharti Rathi, MD FIGURE 1. Coronal ( A) and axial ( B) T1- enhanced MRI scans show multiple confluent round masses filling the suprasellar and perimesencephalic cisterns. The ventricles are dilated, reflecting obstruction of cerebrospinal fluid drainage in the region of the foramen of Monro. Abstract: A 14- year- old girl developed fever, severe headache, vomiting, and no light perception in both eyes over a 3- day period without a previous complaint of visual or other neurologic difficulties. Neuro- ophthalmologic examination was normal apart from meningismus and blind- Departments of Neurosurgery, Neuro- Ophfhalmology ( KS, AV), Neurology ( SP), and Radiodiagnosis ( BR), Sanjay Gandhi Post Graduate Institute of Medical Sciences, Luc know, India. Reprints: Dr. Kumudini Sharma, Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute Of Medical Sciences, Lucknow ( U. P), 226014, India. E- mail: kumud@ sgpgi. ac. in ness. Brain imaging showed ventriculomegaly and multiple enhancing nodules around the optic chiasm. Lumbar puncture showed an elevated opening pressure with lymphocytic pleocytosis. Polymerase chain reaction and enzyme- linked immunoabsorbent antibody tests on the cerebrospinal fluid were positive for Mycobacterium tuberculosis. There was no evidence of tuberculosis elsewhere in the body. Standard antituberculous treatment, including corticosteroids, did not reverse the blindness. ( JNeuro- Ophthalmol 2003; 23: 211- 212) Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. J Neuro- Ophthalmol, Vol. 23, No. 3, 2003 211 JNeuro- Ophthalmol, Vol. 23, No. 3, 2003 Sharma et al A 14- year- old girl experienced holocranial headache, body ache, fever, and vomiting for 2 weeks. Thereafter she noticed progressive visual loss in both eyes leading to complete blindness in 3 days and a single generalized seizure. There was no history of skin rash, joint pain, camping in the woods, or contact with tuberculosis. The daughter of a physician, she had had no prior visual or constitutional symptoms. She was conscious and cooperative but had no perception of light in either eye. Ocular movements were full; pupils were semidilated and showed no reaction to light. Ophthalmoscopy was normal. Neck flexion and straight leg raising elicited neck pain, but otherwise the neurologic examination was normal. A hemogram was normal, but the erythrocyte sedimentation rate was elevated at 27 mm/ hour. Standard blood chemistries were normal, as was a vasculitis profile. Serum IgM for Borrelia burgdorferi, smear for malaria, urinalysis, and chest radiograph were unremarkable. On lumbar puncture, cerebrospinal fluid ( CSF) pressure was raised but not quantitated; CSF protein was 61 mg%, sugar was 7 mg%, and white blood cells were 175/ mm3 ( lymphocytes 95%). Cryptococcal antigen was negative. CSF smear was negative for acid- fast bacillus ( AFB), cap-sulated bacteria, or fungus. CSF culture did not show any AFB or fungal growth. Mantoux test was positive, showing a 20- mm- diameter wheal with flare. Polymerase chain reaction and enzyme- linked immunoabsorbent antibody IgM for Mycobacterium tuberculosis were positive in CSF ( 38.5; normal less than 22). Brain magnetic resonance imaging ( MRI) revealed multiple nodular enhancing lesions in the suprasellar cistern; some lesions were solitary, while others show conglomeration, a finding consistent with tuberculosis ( Fig. 1). She was treated with a standard regimen of antituberculous medications ( oral rifampicin 450 mg/ d, oral isoniazid 300 mg/ d, intramuscular streptomycin 1500 mg/ day), oral prednisolone 1 mg/ kg/ d, and carbamazepine 600 mg/ d. Because of the elevated intracranial pressure, oral acetazolamide 750 mg/ d was also prescribed. Vision remained no light perception in both eyes, so a surgical transfrontal " cleaning" of the chiasmatic cistern was performed at another institution. Six months later, she remains completely blind. Imaging has not been repeated. DISCUSSION A central nervous system infection with M. tuberculosis causes a granulomatous inflammatory reaction that involves the meninges and/ or parenchyma. Visual symptoms in tuberculous meningitis are often due to optic neuritis ( papillitis or retrobulbar neuritis) or opticochiasmatic arachnoiditis. The latter appears on MRI as basal meningeal thickening, often with contrast enhancement. Rarely may masses or tuberculomas form within or adjacent to intracranial portions of the optic nerve or optic chiasm ( 1,2). Multiple tuberculomas occupying the entire suprasellar cistern, as seen in our case, have not been described so far. Visual loss produced by tuberculomas is usually insidious in onset and gradually progressive. These lesions are to be differentiated from other inflammatory granulomas, including sarcoidosis, as well as lymphoma. REFERENCES 1. Miller NR, Newman NJ. Walsh and Hoyt's Clinical N'euro-ophthalmology Volume 4, 5th ed. Baltimore: Williams & Wilkins. 1998. 2. Lesoin F, Dubois F, Rousseaux M, et al. Tuberculomes chiasma-tiques, deux observations. Semin Hop Paris 1984; 60: 1185- 8. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 212 © 2003 Lippincott Williams & Wilkins |
