Cerebral tubercoloma in an HIV positive patient

AM is a 32-year-old female patient; she was admitted in our hospital with complains of right hemiplegia of recent onset.

AM was borne mentally retarded.

She developed symptoms of partial convulsions 3 months ago. At the beginning the twitching involved only the right upper limb.

The family did not take the convulsive disorder seriously and the condition became worse up to 2 months ago when the patient developed paralysis of the right side of the body. At the moment, apart from the hemiplegia, AM complains of tonic-clonic generalized convulsions (Jacksonian).

Our first diagnosis was of CVA (cerebro-vascular accident) or SOL (space occupying lesion). We were also thinking of possible brain haemorrhage.

AM was presented to physiotherapist who strongly recommended a CT scan of the brain. Even before being able to do the scan we tested for HIV, because we noted a full haemogram with total lymphocyte count of 500.

Unfortunately the HIV test was positive. After CD4 count and viral load we started with ART.

The fact that AM is mentally disabled has made the counseling practically impossible and we decided to inform the parents. Of course they were shocked about the news of immunosuppression because they were wondering if somebody could have violated her taking the advantage of her mental condition. We tried to calm them down considering the fact that the patient was transfused in the past.

Thereafter we sent her for CT scan and we got a surprising finding: “extensive hypodense lesion in the left temporal region with a small hyperdense lesion at the centre, seen on o i.v. contrast. Slight mass effect. Conclusion: suggestive of tuberculoma of the left temporal region with a lot of associated oedema”.

The poor AM has therefore got a very rare form of TB which is to be considered as an opportunistic infection due to full blown AIDS.

She is now on treatment with ART, together with TB treatment; she also on prophylaxis for PCP.

For the epileptic disorder we have chosen to use VALPROATE.

We still don’t know if the above treatment associated with physiotherapy will be able to make the hemiplegia improve.

Br Beppe