A 54-year-old man with an underlying
AIDS experienced
fever and
lethargy. Magnetic resonance imaging (MRI) showed multiple small ring-enhancement lesions over pons, basal
ganglion, thalami, and bilateral cerebral hemisphere. Because of the concurrent
pulmonary tuberculosis (TB), presumptive diagnosis of
tuberculous meningitis and brain
tuberculoma was made. The patient's condition clinically improved after a 3-month anti-TB treatment coupled with
highly active antiretroviral therapy (
HAART), and his CD4-T lymphocyte count was increased from 17 cells/mm(3) (HIV viral load, 294,000 copies per milliliter) to 153 cells/mm(3) (HIV viral load, 5930 copies per milliliter). However, the follow-up MRI disclosed disappearance of some old brain lesions and development of some new ones; some previously identified
tuberculoma became smaller in size, while some other enlarger. Of note, ring-enhanced brain lesions were found over the left frontal lobe and left posterior fossa with perifocal
edema and hyperintensity in diffusion weighted MRI indicating
abscess formation.
Steroid was added based on the presumed paradoxical reaction of brain
tuberculoma. Complete resolution of brain lesions was found on MRI 9 months later.
Tuberculoma should be considered in a patient with
AIDS with numerous intracranial lesions if TB involving other site(s) is definitively diagnosed, especially when the patient is receiving prophylactic
trimethoprim-sulfamethoxazole and/or serologically negative for
toxoplasmosis. Our report demonstrated the peculiar phenomenon of paradoxical reaction of brain
tuberculoma during immune reconstitution and strengthens the belief that additional use of
steroids for paradoxical reaction of brain
tuberculoma is indicated after exclusion of other causes for the progressively enlarging brain lesions.