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I read with great interest the recent case report by Fath-Ordoubadi et al.1 This is an excellent report and the authors are to be congratulated for their good work. They have clearly demonstrated their clinical wisdom. They confirmed the diagnosis through a biopsy as there is no specific clinical or radiological criterion for the diagnosis of tuberculoma of the brain.
These patients usually present with symptoms and signs suggesting an intracranial space occupying lesion. There is generally no extracranial clinical features to suggest the diagnosis of active pulmonary or extrapulmonary tuberculosis nor any definite history of previous pulmonary infection.2 Biopsy of the mass lesion remains the scientific ideal for establishing the diagnosis as in the reported case. This should and must be the approach in parts of the world where tuberculosis is rare, although the procedure is invasive and is not without risk.3 4
We treated a group of 24 consecutive patients including 14 reported during a 10 year period without resorting to biopsy. The treatment was based on a strict selection criteria and the response to a 12 week therapeutic test. Cerebral angiography was done only in the first 10 patients who were admitted to hospital for this purpose. It disclosed avascularity of the mass lesion in all of them. Treatment was generally carried out as outpatients. All patients responded to the therapeutic test and all except one were treated successfully with triple antituberculous drug therapy, for a continued total period of 18 months. A failure of medical treatment occurred in one patient due to non-compliance. In this patient the lesion became smaller and more dense, turning into a calcified 4×2 cm sized irregular mass which needed excision for intractable epilepsy. Another patient needed a ventriculoperitoneal shunt for the treatment of an associated obstructive hydrocephalus There were 18 patients with solitary and six with multiple lesions, the size of the lesions varying from 3×2 cm to 7.5×6 cm. Even the largest tuberculoma resolved to a tiny calcified nodule needing no further treatment after 18 months.
It is our practice to perform serial CT in these patients. Each of our patients underwent an average of five scans during the course of the investigation (plain and contrast scans), treatment (contrast scan only, after three, six, and 18 months of treatment), and follow up (contrast scan only, one year after treatment was discontinued). No patient needed treatment beyond 18 months due to the resolution of the tuberculomas as shown in the serial CT. Complete resolution of the lesion(s) or its resolution to a tiny calcified nodule was taken as the criterion to stop therapy. Follow up scans showed no recurrence. Response to antituberculos therapy can be assessed clinically but the resolution of a tuberculoma can be judged only by CT . No scan was done in this reported patient during the course of the treatment. I would like to know the reason for continuing antituberculous treatment for 27 months and the criteria used to stop therapy.
We thank Choudhury for his kind comments. Our patient also underwent serial CT during the course of his antituberculous treatment. The lesion appeared quiescent some time before therapy was finally stopped; we erred on the side of caution. The final decision to stop treatment was empirical and we would generally support Choudhury’ s view that 18 months of treatment should be sufficient.
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