Intracranial tuberculoma as an immune reconstitution inflammatory syndrome in a man with AIDS, tuberculous meningitis, and diffuse large B-cell lymphoma

Diagnosing intracranial space-occupying lesions in patients with AIDS is challenging because they have multiple possible causes. We report the case of a 49-year-old man with AIDS and diffuse large B-cell lymphoma (DLBCL) who presented with fever and impaired consciousness. He had initiated antiretroviral therapy (ART) and treatment for DLBCL 3 months previously, and treatment for pulmonary tuberculosis and tuberculous meningitis 1 month previously. Gd-DTPA-enhanced magnetic resonance imaging revealed multiple new cerebral ring-enhancing lesions. A left occipital lobe biopsy specimen revealed a necrotic epithelioid granuloma, and Mycobacterium tuberculosis was detected on brain tissue culture, leading to a diagnosis of an intracranial tuberculoma associated with immune reconstitution inflammatory syndrome (IRIS). He was treated with ART, antituberculosis therapy, and dexamethasone, and gradually recovered. This case demonstrates the utility of brain biopsy for confirming the diagnosis of tuberculoma. • A man presented with fever and impaired consciousness. • He had started treatment for AIDS, lymphoma, and TB, 1 to 3 months previously. • Gd-DTPA-enhanced brain MRI revealed multiple new ring-enhancing lesions. • Brain biopsy revealed a necrotic granuloma, culture-positive for M. tuberculosis . • He was diagnosed with a tuberculoma associated with IRIS.