TUBERCULOMA INTRADURAL EXTRAMEDULLARY MIMICKING PRIMARY NEOPLASM IN AN IMMUNOSUPPRESSED PATIENT: RARE PRESENTATION OF NEUROTUBERCULOSIS

Among central nervous system involvement by tuberculosis, intradural spinal tuberculomas are among the rarest presentations, corresponding to less than 5% of all cases. Of these, intradural extramedullary tuberculomas correspond to an even smaller fraction, with small reports and case series in the literature. The present report shows one of these rare entities presenting by mimicking a neoplastic process in an immunosuppressed patient. Female patient, with systemic lupus erythematosus and severely immunosuppressed due to use of prednisone, methotrexate, and rituximab, presented to the emergency service with acute lower-limb deficit and involuntary loss of urine and feces. On initial exam, the patient had decreased strength, grade III bilaterally, hyporeflexia of the lower limbs, and saddle paresthesia, raising the hypothesis of cauda equina syndrome. As follow-up, lumbar spine MRI was requested and revealed multiple intradural nodular masses from L2 to L4. CSF evaluation showed lymphomonocytic meningitis (63 cells/mm³, 95% lymphocytes), with protein 136 mg/dL, ADA 3.6 u/L, glucose 60 mg/dL, negative search for neoplastic cells, and negative immunophenotyping for neoplasia. Given the lack of diagnostic clarification, the patient underwent a surgical approach with removal of the largest mass at L3 measuring 2.3 × 1.6 cm. Pathology showed multiple foci of granuloma formation with intense caseous necrosis and immunohistochemistry negative for neoplasias. In this context, tuberculosis investigation was extended with samples sent for culture and molecular tests, which returned negative. Given the histological finding, the patient’s history of profound immunosuppression, and lack of strength recovery even after surgical removal of the mass, empirical treatment with tuberculostatics was chosen. The patient evolved with good response to treatment, with gradual strength recovery and reduction of remaining masses on imaging control 2 months after initiation of pharmacological treatment, and was discharged for outpatient follow-up. Although rare, spinal tuberculomas should be considered as differential diagnoses in medullary expansive processes, especially in immunosuppressed patients. Rapid surgical decompression and early initiation of pharmacological therapy are essential for treatment and prevention of deficits caused by them.